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 is determined according to individual or group customer benefits.

Reconstructive surgery is performed to improve or restore functional impairment or to alleviate pain and physical discomfort resulting from a condition, disease, illness, 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.

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.

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).

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
12/2003, Blepharoplasty and blepharoptosis coverage and reporting guidelines explained

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)

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

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

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 disease conditions such as chronic pain, dermatitis, or ulceration created by the abdominal skin fold exist.

NOTE:

An indication of pain or a condition such as dermatitis, refractory to medical treatment, can justify surgery as reconstructive in nature.

Blepharoplasty (15820-15823), Brow lift, 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; and,
3. preoperative photographs, maintained in the patient's records, include one view of the patient in primary position, one view looking up and one looking down and should demonstrate one or more of the following:

• The upper eyelid margin within 2.5 mm (1/4 of the diameter of the visible iris) of the corneal light reflex (MRD ≤ 2.5 mm), with patient in primary gaze
• The upper eyelid skin rests on the eyelashes
• The upper eyelid indicates the presence of dermatitis
• The upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmic socket
• The brow position is below the superior orbital rim.

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.

      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.

   4. 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.