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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.63 Reduction Mammaplasties

Procedure code 19318 is the removal of breast tissue and is a benefit of Texas Medicaid when prior authorized.
For prior authorization of reduction mammaplasty, a completed “Medicaid Certificate of Medical Necessity for Reduction Mammaplasty” form signed and dated by the physician, must be submitted and include at least one of the following criteria:
In addition to the above criteria, documentation must indicate:
The following services are not a benefit of Texas Medicaid:
The physician is required to maintain the following documentation in the client’s clinical records:
The physician is required to maintain preoperative photographs (frontal and lateral views) in the client’s clinical records and must be made available to Texas Medicaid upon request.
For reimbursement purposes on a bilateral procedure, the full allowed amount will be paid to the surgeon and assistant surgeon for the first breast reduction and one half the allowed amount will be paid for the second reduction. Facilities are paid for one surgical procedure.
When submitting for prior authorization, requests must be sent to TMHP Special Medical Prior Authorization. Sending requests directly to the TMHP Medical Director delays the processing of the request. Providers are to mail prior authorization requests for reduction mammaplasty to the following address:
Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway, Suite 100
Austin, TX 78727
Fax 1-512-514-4213

Texas Medicaid & Healthcare Partnership
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