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What if an upgraded implant is needed due to a metal allergy? 

Effective July 1, 2019, HealthChoice revised the policy regarding Select inpatient implants allowing additional reimbursement for medically necessary upgrades. If an implant upgrade is deemed medically necessary, then reimbursement of an additional $1,500 allowable will be applied. Claims billed with a diagnosis code of L23.0 or Z91.048 will be reviewed for an additional implant upgrade allowable. Claims that are billed without a qualifying diagnosis are not eligible for the additional implant upgrade reimbursement. Inpatient certification and implant upgrade certifications are handled separately. Certification for any inpatient stay is required in accordance with plan policy and criteria and reviewed by the HealthChoice certification vendor. Separate certification is required through HCMU for implant upgrades. Implant certification requires, in part, a description of the composite makeup of the device, which includes laboratory documentation confirming the patient’s metal allergy. The device must also meet the definition of an implanted prosthetic device. Members of the High Deductible Health Plan must meet their deductible before any benefits, other than for preventive services, are paid by the plan. For more information about certification, please reference the HealthChoice Provider Manual.