Printer Friendly Version

Section: Surgery
Number: S-28
Topic: Cosmetic Surgery vs. Reconstructive Surgery
Effective Date: March 17, 2008
Issued Date: August 18, 2008
Date Last Reviewed:

General Policy Guidelines

Indications and Limitations of Coverage

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.

Procedure Codes

157751577615780157811578215783
157861578715788157891579215793
158101581115820158211582215823
158241582515826158281582915830
158321583315834158351583615837
158381583915847158761587715878
158791700017003170041710617107
171081734017360173801799919300
193181932419325193551949930400
304103042030430304353045036468
364696790067901679026790367904
679066930096900L8600  

Traditional (UCR/Fee Schedule) Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Reconstructive Surgery/Covered:

*Surgery to correct a functional defect

*Surgery to correct a congenital anomaly - a condition that existed at or from birth and is a significant deviation from the common form or norm.  Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes.
Note: congenital anomalies do not include conditions related to the teeth or intra-oral structures supporting the teeth.

*Treatment to restore the mouth to a pre-cancer state

*All stages of breast reconstruction surgery following a mastectomy, such as:

-surgery to produce a symmetrical appearance of the patient's breasts
-treatment of any physical complications, such as lymphedemas

*Surgery for placement of penile prostheses to treat erectile dysfunction

Cosmetic Surgery/Not covered:

*Cosmetic surgery - any operative procedure or any portion of a procedure performed primarily to improve physical appearance through change in bodily form - unless required for a congenital anomaly or to restore or correct a part of the body that has been altered as a result of accidental injury, disease, or surgery (does not include anomalies related to the teeth or structures supporting the teeth)

*Surgeries related to sex transformation, sexual dysfunction, or sexual inadequacy (except for surgical placement of penile prosthesis to treat erectile dysfunction resulting from prostatectomy to treat prostate cancer)

Comprehensive / Wraparound / PPO / Major Medical Guidelines

Refer to General Policy Guidelines

Any reference in this bulletin to non-billable services by a network provider may not be applicable to Major Medical.

Managed Care (HMO/POS) Guidelines

Managed Care The leading cause of enlarged breasts in males is obesity. In order for mastectomy for gynecomastia (19300) 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
12/2003, Blepharoplasty and blepharoptosis coverage and reporting guidelines explained
04/2004, Abdominoplasty surgery coverage and reporting guidelines explained
04/2007, Coverage criteria for breast reduction surgery explained
12/2007, Otoplasty to improve hearing impairment considered reconstructive surgery
12/2007, New coverage guidelines for treating port wine stains and rosacea begin March 2008

References

Auricular Reconstruction for Microtia: Part 1: Anatomy, Embryology, and Clinical Evaluation, Plast Reconstr Surg, Volume 9, No. 7, 06/2002

Microtia Reconstruction: an Update [Review], Curr Opin Otolaryngol Head Neck Surg., Volume 11, No. 4, 08/2003

Description and Analysis of the Treatments for Port-Wine Stain (PWS) Birthmarks, Arch Facial Plast Surg, Volume 7, No.5, 9-10/2005

Redarking of Port-Wine Stains 10 Year After Pulsed-Dye Laser Treatment, New England Journal of Medicine, Volume 356, No. 12, 03/2007

Basal Cell Carcinoma Arising Over Facial Port Wine Stain, A Single-Center Experience, J Eur Acad Dermatol Venerereol, Volume 20, No. 9, 10/2006

Laser Treatment of Vascular Lesions, Dermatologic Clinics, Volume 23, No. 4, 10/2005

Sturge-Weber Syndrome: Deep Venous Occlusion and the Radiologic Spectrum, Pediatric Neurology, Volume 35, No. 5, 11/2006

Lasers and Light Sources for Rosacea, Cutis, Volume 75, No. 3 Suppl, 03/2005

Present and Future Rosacea Therapy, Cutis, Volume 75 No. 3 Suppl, 03/2005

Rosacea in a New Light SKINmed, Volume 4, No.1, 2005

Laser and Light Therapies for Acne Rosacea, J Drugs Dermatol, Volume 5, No. 1, 01/2006

 

 

View Previous Versions

[Version 015 of S-28]
[Version 014 of S-28]
[Version 013 of S-28]
[Version 012 of S-28]
[Version 011 of S-28]
[Version 010 of S-28]
[Version 009 of S-28]
[Version 008 of S-28]
[Version 007 of S-28]
[Version 006 of S-28]
[Version 005 of S-28]
[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)
3 10 50 90 97  
               5 Years
       34.5        36.6        42.8        49.7        53.2 Weight in lbs.
       15.65        16.6        19.41        22.54        24.13 Weight in kg.
       40.2        41.5        43.8        45.9        47.0 Height in in.
       102.1        105.3        111.3        116.7        119.5 Height in cm
         
     6 Years
       38.5        40.9        48.3        56.4        61.1 Weight in lbs.
       17.46        18.55        21.91        25.58        27.71 Weight in kg.
       42.7        43.8        46.3        48.6        49.7 Height in in.
       108.5        111.2        117.5        123.5        126.2 Height in cm
         
     7 Years
       43.0        45.8        54.1        64.4        69.9 Weight in lbs.
       19.5        20.77        24.54        29.21        31.71 Weight in kg.
       44.9        46.0        48.9        51.4        52.5 Height in in.
       114.0        116.9        124.1        130.5        133.4 Height in cm
         
     8 Years
       48.0        51.2        60.1        73.0        79.4 Weight in lbs.
       21.77        23.22        27.26        33.11        36.02 Weight in kg.
       47.1        48.5        51.2        54.0        55.2 Height in in.
       119.6        123.1        130.0        137.3        140.2 Height in cm
         
     9 Years
       52.5        56.3        66.0        81.0        89.8 Weight in lbs.
       23.81        25.54        29.94        36.74        40.73 Weight in kg.
       48.9        50.5        53.3        56.1        57.2 Height in in.
       124.2        128.3        135.5        142.6        145.3 Height in cm
         
     10 Years
       56.8        61.1        71.9        89.9        100.0 Weight in lbs.
       25.76        27.71        32.61        40.78        45.36 Weight in kg.
       50.7        52.3        55.2        58.1        59.2 Height in in.
       128.7        132.8        140.3        147.5        150.3 Height in cm
         
     11 Years
       61.8        66.3        77.6        99.3        111.7 Weight in lbs.
       28.03        30.07        35.2        45.04        50.67 Weight in kg.
       52.5        54.0        56.8        59.8        60.8 Height in in.
       133.4        137.3        144.2        151.8        154.4 Height in cm
         
     12 Years
       67.2        72.0        84.4        109.6        124.2 Weight in lbs.
       30.48        32.66        38.28        49.71        56.34 Weight in kg.
       54.4        56.1        58.9        62.2        63.7 Height in in.
       138.1        142.4        149.6        157.9        161.9 Height in cm
         
     13 Years
       72.0        77.1        93.0        123.2        138.0 Weight in lbs.
       32.66        34.97        42.18        55.88        62.6 Weight in kg.
       56.0        57.7        61.0        65.1        66.7 Height in in.
       142.2        146.6        155.0        165.3        169.5 Height in cm
         
     14 Years
       79.8        87.2        107.6        136.9        150.6 Weight in lbs.
       36.2        39.55        48.81        62.1        68.31 Weight in kg.
       57.6        59.9        64.0        67.9        69.7 Height in in.
       146.4        152.1        162.7        172.4        177.1 Height in cm
         
     15 Years
       91.3        99.4        120.1        147.8        161.6 Weight in lbs.
       41.41        45.09        54.48        67.04        73.3 Weight in kg.
       59.7        62.1        66.1        69.6        71.6 Height in in.
       151.7        157.8        167.8        176.7        181.8 Height in cm
         
     16 Years
       103.4        111.0        129.7        157.3        170.5 Weight in lbs.
       46.9        50.35        58.83        71.35        77.34 Weight in kg.
       61.6        64.1        67.8        70.7        73.1 Height in in.
       156.5        162.8        171.6        179.7        185.6 Height in cm
         
     17 Years
       110.5        117.5        136.2        164.6        175.6 Weight in lbs.
       50.12        53.3        61.78        74.66        79.65 Weight in kg.
       62.6        65.2        68.4        71.5        73.5 Height in in.
       159.0        165.5        173.7        181.6        186.6 Height in cm
         
     18 Years
       113.0        120.00        139.0        169.0        179.0 Weight in lbs.
       51.26        54.43        63.05        76.66        81.19 Weight in kg.
       62.8        65.5        68.7        71.8        73.9 Height in in.
       159.6        166.3        174.5        182.4        187.6 Height 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 noncovered procedures.

  • 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)
  • Microdermabrasion (17999) (See Category B for guidelines on dermabraion.)
  • Temporary hair removal (e.g., waxing, laser)
    (See Category B for guidelines on permanent hair removal.)
  • 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 via any treatment modality (e.g., laser, cryotherapy) performed solely for the treatment of post-acne scarring.
  • Rosacea (695.3) treatment (any non-pharmacological treatment method, including but not limited to, laser and light therapy (e.g., intense pulsed light [IPL], dermabrasion, chemical peels, surgical debulking, and electrosurgery)
CATEGORY B - COVERED PROCEDURES
See Medical Policy Bulletin S-74 for covered suction assisted lipectomy services.

See Medical Policy Bulletin S-76 for guidelines on the removal of breast implants.

See Medical Policy Bulletin S-55 for treatment by injection of sclerosing solution into varicose veins.

Payment will be made for the following potentially cosmetic procedures as reconstructive surgery when performed for the reasons indicated:

  1. Panniculectomy, Abdominoplasty ("Tummy Tuck") (15830, 15847, 17999): When: (a) the panniculus or fold hangs at or below the level of the pubis; and (b) the medical records document that the panniculus or fold causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs or remains refractory to appropriate medical therapy (i.e., treatment of the rash includes prescription medications) over a period of three months. 

    NOTE:
    Report procedure code 15830 (Excision, excessive skin and subcutaneous tissue [includes lipectomy]; abdomen, infraumbilical panniculectomy) when performing a panniculectomy.  Report procedure codes 15830 and 15847 (Excision, excessive skin and subcutaneous tissue [includes lipectomy], abdomen [e.g., abdominoplasty] includes umbilical transposition and fascial plication) when an abdominoplasty is performed with a panniculectomy.  Procedure code 15847 should only be reported with procedure code 15830.  When an abdominoplasty is performed without panniculectomy, report procedure code 17999 with a description of the service.

  2. 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 ophthalmic socket
    • The brow position is below the superior orbital rim.

    Note:  When the physician has determined that the patient requires a bilateral blepharoplasty, bilateral blepharoptosis repair or a bilateral brow ptosis repair, it is expected that the procedures will be performed on the same date of service.  Bilateral procedures performed on different dates of service require the submission of medical record documentation to support the medical necessity of performing these procedures on different dates of service.

  3. Breast Surgery:

    1. Reduction mammoplasty (breast reduction)(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 stature (5'5").

      Note:  For women of small stature, the following sliding scale may be used to determine the required grams removed.

       Height Grams 
       5'5"  700
       5'4"  650
       5'3"  600
       5'2"  550
       5'1"  500
       5'0"  465
       4'11"  435
       4'10"  400

      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 (19300): 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.
  4. Cryotherapy (17340): When performed for diagnoses other than active acne. Cryotherapy performed for the treatment of active acne is classified as cosmetic and is not eligible for payment.

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

  6. 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.

  7. Hair Removal (Permanent) by any method (e.g., by electrolysis (17380):

    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:
    Electrolysis (17380) and laser hair removal (17999) performed for hirsutism are  classified as cosmetic and not eligible for payment.

  8. Hair Transplant (15775-15776): When performed as a result of injury or burn.

  9. Otoplasty (69300): When performed to improve hearing impairment, whether the ears are absent or deformed from trauma, surgery, disease, or congenital defect.  Hearing impairment is defined as a loss of at least 15 decibels outside the normal hearing range in the affected ear(s) documented by audiogram.  (Note:  Degree of hearing loss refers to the severity of the loss.  Normal range or no hearing loss = 0dB to 20dB.)

  10. Port Wine Stain Treatment (17106-17108): For lesions on the face and neck.  Treatment of lesions on the trunk or extremities is considered cosmetic.

  11. Rhinoplasty (30400-30450):

    1. When post-traumatic (i.e. accident) nasal deformity exists or
    2. When functional breathing impairment is present.

  12. Rhytidectomy (15824-15829) (meloplasty, face lift): When functional impairment as a result of a disease state exists (e.g., facial paralysis).

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

Procedure Code Attachment


Glossary





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.



back to top