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Section: Surgery
Number: S-28
Topic: Cosmetic Surgery vs. Reconstructive Surgery
Effective Date: January 1, 2003
Issued Date: January 13, 2003
Date Last Reviewed:

General Policy Guidelines | Procedure Codes | Traditional (UCR/Fee Schedule) Guidelines | FEP Guidelines | Comprehensive/Wraparound/PPO Guidelines | Managed Care (HMO/POS) Guidelines | Publications | View Previous Versions | Attachments | Glossary

General Policy Guidelines

Cosmetic surgery is performed to improve an individual's appearance and is generally ineligible for payment. However, cosmetic surgery is eligible when performed to correct a condition resulting from an accident.

Note:
Coverage for cosmetic services may vary and will be identified in benefits.
Reconstructive surgery is performed to improve or restore function impairmant resulting from a disease, injury, or congenital birth defect. Reconstructive surgery is generally eligible for payment.
Note:
An indication or a diagnosis of "pain" may qualify as functional impairment.
Corrective facial surgery will be considered cosmetic rather than reconstructive when there is no functional impairment present.

Psychiatric indications do not warrant payment for cosmetic surgery when no functional impairment is present. However, severe psychological impairment, appropriately documented, can be classified as "significant functional impairment" on an individual consideration basis.

In cases involving psychiatric disorder or involutional changes due to aging, the claim should be accompanied by a report from a psychiatrist which indicates a definite psychiatric condition relevant to the condition to be corrected by the surgery and that the proposed correction is likely to be of significant help in treating the psychiatric problem. These services require medical review prior to payment.

Some common procedures which may be classified as cosmetic or reconstructive surgery are listed on the Text Attachment below (Categories A & B). These guidelines should be used to determine whether those procedures are cosmetic or reconstructive. There may be other procedures which could be performed for either cosmetic or reconstructive purposes. These procedures should be reviewed on an individual consideration basis and classified as reconstructive surgery only when there is documented functional impairment.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

157751577615780157811578215783
157861578715788157891579215793
158101581115820158211582215823
158241582515826158281582915831
158321583315834158351583615837
158381583917106171071710817340
173601738019140193181932419325
193551949930400304103042030430
304353045036468364696790067901
6790267903679046790669300L8600

Traditional (UCR/Fee Schedule) Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Payment may be made only for surgery which restores or improves a bodily function or restores its appearance as it existed prior to an accidental injury, disease or surgery, when symptoms are present.

Cosmetic surgery is covered for the restoration or correction of a part of the body to restore the normal function of the body part or to restore its appearance as it existed prior to the accidental injury, disease or surgery in the absence of symptoms.

FEP also provides benefits for the correction of the congenital or developmental anomalies. Additionally, there is no age limit for coverage of corrective surgery for congenital anomalies. Congenital anomalies include harelip, webbed fingers or toes, or other conditions the carrier may determine to be congenital anomalies. Surgery for congenital anomalies relating to teeth or structures supporting the teeth is not covered.

Blepharoplasty and blepharoptosis of lower lids for ectropion, dry eye or corneal ulcer is covered.

Dermabrasion and cryotherapy performed for the treatment of severe acne scarring is covered.

Hair transplant when performed as a result of disease, trauma or therapeutic processes is covered.

Also refer to General Policy Guidelines

Comprehensive/Wraparound/PPO Guidelines

Refer to General Policy Guidelines

Managed Care (HMO/POS) Guidelines

Managed Care (Western Region Only)

The leading cause of enlarged breasts in males is obesity. In order for mastectomy for gynecomastia (19140) to be considered reconstructive rather than cosmetic surgery, the following guidelines should be applies:

  • Ages 5 - 18 years - The patient must be below the 97th percentile for weight based on height as indicated on the standard pediatric growth and development chart (See the Table Attachment below).


  • Ages 19 - 24 years - The patient's weight must be within the ideal weight for a 25 year old as indicated on the Metropolitan Life Height and Weight Table for Men. (The ideal weight for 19 24 years is the same, or close to, the 25 year weights because this age range is past puberty.) (See the Table Attachment below).


  • Ages 25 - 59 years - The patient's weight must be within the ideal body weight as indicated on the Metropolitan Life Height and Weight Table for Men (See the Table Attachment below).
If the patient's weight does not fall within these guidelines, the surgery will be considered cosmetic until the pathology report confirms that the tissue removed was primarily breast (ductal) rather than adipose (fat) tissue.

Also refer to General Policy Guidelines

Publications

PRN References

04/1993, Cryotherapy for the treatment of acne
10/1994, Septorhinoplasty performed by two surgeons, reporting of
06/1995, 02/1996, Preauthorizations for cosmetic versus reconstructive surgery
04/1998, Port wine stains treatment now covered
04/2001, Correction of inverted nipples considered cosmetic in most cases

References

View Previous Versions

[Version 004 of S-28]
[Version 003 of S-28]
[Version 002 of S-28]
[Version 001 of S-28]

Table Attachment

Metropolitan Life Height & Weight Table for Men
Height
Feet Inches
Small
Frame
Medium
Frame
Large
Frame
           5'2"           128-134           131-141           138-150
           5'3"           130-136           133-143           140-153
           5'4"           132-138           135-145           142-156
           5'5"           134-140           137-148           144-160
           5'6"           136-142           139-151           146-164
           5'7"           138-145           142-154           149-168
           5'8"           140-148           145-157           152-172
           5'9"           142-151           148-160           155-176
           5'10"           144-154           151-163           158-180
           5'11"           146-157           154-166           161-184
           6'0"           149-160           157-170           164-188
           6'1"           152-164           160-174           168-192
           6'2"           155-168           164-178           172-197
           6'3"           158-172           167-182           176-202
           6'4"           162-176           171-187           181-207

Weights at ages 25-59 based on lowest mortality. Weight in pounds according to frame (in indoor clothing weighing 5 lbs. for men and 3 lbs. for women; shoes with 1" heels)

Pediatric Growth Chart - Percentiles for Weight Based on Height

Percentiles (Boys)
310509097 
          5 Years
       34.5       36.6       42.8       49.7       53.2Weight in lbs.
       15.65       16.6       19.41       22.54       24.13Weight in kg.
       40.2       41.5       43.8       45.9       47.0Height in in.
       102.1       105.3       111.3       116.7       119.5Height in cm
     
     6 Years
       38.5       40.9       48.3       56.4       61.1Weight in lbs.
       17.46       18.55       21.91       25.58       27.71Weight in kg.
       42.7       43.8       46.3       48.6       49.7Height in in.
       108.5       111.2       117.5       123.5       126.2Height in cm
     
     7 Years
       43.0       45.8       54.1       64.4       69.9Weight in lbs.
       19.5       20.77       24.54       29.21       31.71Weight in kg.
       44.9       46.0       48.9       51.4       52.5Height in inc.
       114.0       116.9       124.1       130.5       133.4Height in cm
     
     8 Years
       48.0       51.2       60.1       73.0       79.4Weight in lbs.
       21.77       23.22       27.26       33.11       36.02Weight in kg.
       47.1       48.5       51.2       54.0       55.2Height in in.
       119.6       123.1       130.0       137.3       140.2Height in cm
     
     9 Years
       52.5       56.3       66.0       81.0       89.8Weight in lbs.
       23.81       25.54       29.94       36.74       40.73Weight in kg.
       48.9       50.5       53.3       56.1       57.2Height in in.
       124.2       128.3       135.5       142.6       145.3Height in cm
     
     10 Years
       56.8       61.1       71.9       89.9       100.0Weight in lbs.
       25.76       27.71       32.61       40.78       45.36Weight in kg.
       50.7       52.3       55.2       58.1       59.2Height in in.
       128.7       132.8       140.3       147.5       150.3Height in cm
     
     11 Years
       61.8       66.3       77.6       99.3       111.7Weight in lbs.
       28.03       30.07       35.2       45.04       50.67Weight in kg.
       52.5       54.0       56.8       59.8       60.8Height in in.
       133.4       137.3       144.2       151.8       154.4Height in cm
     
     12 Years
       67.2       72.0       84.4       109.6       124.2Weight in lbs.
       30.48       32.66       38.28       49.71       56.34Weight in kg.
       54.4       56.1       58.9       62.2       63.7Height in in.
       138.1       142.4       149.6       157.9       161.9Height in cm
     
     13 Years
       72.0       77.1       93.0       123.2       138.0Weight in lbs.
       32.66       34.97       42.18       55.88       62.6Weight in kg.
       56.0       57.7       61.0       65.1       66.7Height in in.
       142.2       146.6       155.0       165.3       169.5Height in cm
     
     14 Years
       79.8       87.2       107.6       136.9       150.6Weight in lbs.
       36.2       39.55       48.81       62.1       68.31Weight in kg.
       57.6       59.9       64.0       67.9       69.7Height in in.
       146.4       152.1       162.7       172.4       177.1Height in cm
     
     15 Years
       91.3       99.4       120.1       147.8       161.6Weight in lbs.
       41.41       45.09       54.48       67.04       73.3Weight in kg.
       59.7       62.1       66.1       69.6       71.6Height in in.
       151.7       157.8       167.8       176.7       181.8Height in cm
     
     16 Years
       103.4       111.0       129.7       157.3       170.5Weight in lbs.
       46.9       50.35       58.83       71.35       77.34Weight in kg.
       61.6       64.1       67.8       70.7       73.1Height in in.
       156.5       162.8       171.6       179.7       185.6Height in cm
     
     17 Years
       110.5       117.5       136.2       164.6       175.6Weight in lbs.
       50.12       53.3       61.78       74.66       79.65Weight in kg.
       62.6       65.2       68.4       71.5       73.5Height in in.
       159.0       165.5       173.7       181.6       186.6Height in cm
     
     18 Years
       113.0       120.00       139.0       169.0       179.0Weight in lbs.
       51.26       54.43       63.05       76.66       81.19Weight in kg.
       62.8       65.5       68.7       71.8       73.9Height in in.
       159.6       166.3       174.5       182.4       187.6Height in cm

[Figures are from studies by Howard V. Meredith, Iowa Child Welfare Research Station, The State University of Iowa.]

Text Attachment

 

CATEGORY A - NONCOVERED PROCEDURES
Payment will not be made for the following procedures except on an inquiry basis. These procedures will be given individual consideration:
  • Excision, excessive skin, thigh, leg, hip, buttock, arm, forearm, or hand, submental fat pad, other area (15832-15839)
  • Chemical peel(15788-15793)
  • Correction of diastasis recti abdominis
  • Salabrasion (15810, 15811)
  • Chemical exfoliation for acne (17360)
  • Temporary hair removal (e.g., waxing)
    (See Category B for guidelines on permanent hair removal.)
Payment will not be made for the following procedures. They are non-covered under all circumstances:
  • Suction assisted lipectomy done solely for cosmetic purposes (15876-15879)
  • Removal of spider angiomata (36468, 36469) (See Medical Policy Bulletin S-55)
  • Procedures/products/services performed solely for the treatment of post-acne scarring.
CATEGORY B - COVERED PROCEDURES
See MPB S-74 for covered suction assisted lipectomy services.

See MPB S-76 for guidelines on the removal of breast implants.

See MPB S-55 for treatment by injection of sclerosing solution into varicose veins.
Note:
The treatment of port wine stains and rosacea (17106-17108) is not considered cosmetic and is eligible for payment under all programs.
Payment will be made for the following potentially cosmetic procedures as reconstructive surgery when performed for the reasons indicated:
Abdominal lipectomy (15831): When symptomatic diseaseconditions such as chronic pain, dermatitis, or ulceration created by the abdominal skin fold exist.

Blepharoplasty (15820-15823) and Blepharoptosis(67900-67906):When visual impairment is documented by:
  1. an automated visual field study, interpreted by the doctor who performed the study and
  2. a statement from the doctor who performed the visual field study that the visual deficit shown by the study is caused by the eyelid's condition and that the proposed surgery is being performed in an attempt to correct the visual deficit.
Breast Surgery:
  1. Reduction mammoplasty (19318):
    1. When severe symptomatic hyperplasia (hypermastia) exists; and
    2. there must be documentation that the size and weight of the breasts are causing symptoms; and
    3. there must be a minimum of 700 grams (total) removal bilaterally for patients of average height and weight.
    Note:
    All questionable cases or cases involving women of very small stature are entitled to individual consideration.
  2. Augmentation mammoplasty (19324-19325):
    1. When unilateral breast aplasia is present.
    2. Following extirpative surgery for benign disease (e.g., subcutaneous mastectomy with either immediate or delayed (second stage)prosthesis).
    3. When a reconstructive procedure is performed following previous radical surgery for malignant disease.
    4. Note:
      Effective February 1, 1998, surgery on an unaffected breast in order to provide symmetry with a breast on which a mastectomy and reconstructive procedure have been performed is eligible for payment.

      Charges for an implantable breast prosthesis (L8600) are eligible when the implant is provided in conjunction with a reconstructive augmentation mammoplasty. However, if the augmentation mammoplasty is classified as cosmetic, charges for the implant should be denied as cosmetic.
    5. When breast hypoplasia (affected breast) is associated with Poland's syndrome.
  3. Nipple tattooing (19499):
    1. When performed as part of a reconstructive procedure following radical surgery (e.g., mastectomy for benign or malignant disease).
    2. When performed following an injury (e.g., burn).
  4. Mastectomy for gynecomastia (19140): If it is documented that the tissue is primarily breast tissue and not just adipose (fatty) tissue. If the tissue removed is primarily fatty tissue, the surgery is classified as cosmetic and is not eligible for payment.
  5. Correction of inverted nipples (19355): When performed in attempt to restore the ability to breast feed.
Note:
For additional guidelines on reconstructive surgery and breast prosthetics following mastectomy, see Medical Policy Bulletin S-129.
Cryotherapy (17340): When performed for diagnoses other than acne. Cryo-therapy performed for the treatment of acne is classified as cosmetic and is not eligible for payment.

Dermabrasion (15780-15787):When correcting defects resulting from an accident or when functional impairment exists.

Earlobe Surgery: When repairing an earlobe defect if the defect is a "through and through" laceration resulting in a "bilobe earlobe", payment should be made under the appropriate laceration repair code. Repair of a defect that does not result in a "bilobe earlobe" (e.g., a large hole resulting from wearing heavy jewelry) is classified as cosmetic and is not eligible for payment.

Hair Removal (Permanent) (e.g., by electrolysis (17380), laser):
  1. When performed to prevent the recurrence of pilonidal cysts.
  2. When ingrown hairs are responsible for repeated painful cysts, targeted hair removal is appropriate.
Note:
When electrolysis (17380) is performed for hirsutism, it is classified as cosmetic and is not eligible for payment.
Hair Transplant (15775-15776): When performed as a result of injury or burn.

Otoplasty (69300): For significant congenital or acquired malformation.

Rhinoplasty (30400-30450):
  1. When post-traumatic (i.e. accident) nasal deformity exists or
  2. When functional breathing impairment is present.
Rhytidectomy (15824-15829) (meloplasty, face lift): When functional impairment as a result of a disease state exists (e.g., facial paralysis).

Scar Revision: When correcting scars and keloids resulting from an accident or when functional impairment exists.

Procedure Code Attachment


Glossary

TermDescription






Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.



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