||Cosmetic Surgery vs. Reconstructive Surgery
||August 23, 2010
||August 23, 2010
|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 may be eligible when performed to correct a condition resulting from an accident.
- 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.
- 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 potentially cosmetic may also be considered reconstructive. The guidelines above should be used to determine whether those procedures are cosmetic or reconstructive. Please see the Text Attachment for a listing of some of the common procedures. 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.
- 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.
Traditional (UCR/Fee Schedule) Guidelines
*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 as specifically shown above
Comprehensive / Wraparound / PPO / Major Medical 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
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
02/2009, Coverage guidelines for treating rosacea revised
02/2009, Reporting guidelines for certain cosmetic vs. reconstructive procedures explained
04/2010, Coverage criteria for mastectomy for gynecomastia revised
04/2010, Cathopexy considered reconstructive surgery when performed for specific conditions
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
American Society of Plastic Surgeons. Practice Parameters, Gynecomastia. Feb 2004. Available at URL address: www.plasticsurgery.org
National Center for Health Services. Body Mass Index for Age Tables, Children Ages 2-20 years, Selected Percentiles. Available at URL address: www.cdc.gov/nchs/nhanes/growthcharts/html_charts/bmiagerev.htm
View Previous Versions
The following procedures can be performed for either cosmetic or reconstructive purposes.
If there are no procedure specific guidelines associated with a listed procedure below, the procedure may be classified as reconstructive only when there is documented functional impairment, as defined in the general policy guidelines.
- 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 (17999)
- Chemical exfoliation for acne (17360)
- Microdermabrasion (17999)
- Temporary hair removal (e.g., waxing, laser)
- Suction assisted lipectomy done solely for cosmetic purposes (15876-15879) (See Medical Policy Bulletin S-74 for covered suction assisted lipectomy services.)
- Removal of spider angiomata (36468, 36469) (See Medical Policy Bulletin S-55 for treatment by injection of sclerosing solution into varicose veins.)
- Procedures/products/services via any treatment modality (e.g., laser, cryotherapy ) performed solely for the treatment of post-acne scarring.
If all the procedures specific guidelines below are met, the following procedures are considered reconstructive and eligible for payment.
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.
- 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.
Blepharoplasty (15820-15823), Brow lift, and Blepharoptosis(67900-67906): When visual impairment is documented by:
- an automated visual field study, interpreted by the doctor who performed the study; and,
- 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,
- 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.
- 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.
Canthopexy (21280, 21282): When performed for the following conditions:
- Presence of corneal or conjunctival staining
- Mucous membrane changes
- Documentation of epiphora and poor closure of the lids
- Bell's palsy
Breast Surgery :
- Reduction mammoplasty (breast reduction)(19318):
- when severe symptomatic hyperplasia (hypermastia) exists; and
- there must be documentation that the size and weight of the breasts are causing symptoms; and
- 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.
All questionable cases or cases involving women of very small stature are entitled to individual consideration.
- Augmentation mammoplasty (19324-19325):
- When unilateral breast aplasia is present.
- Following extirpative surgery for benign disease (e.g., subcutaneous mastectomy with either immediate or delayed (second stage)prosthesis).
- When a reconstructive procedure is performed following previous radical surgery for malignant disease.
- 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.
- When breast hypoplasia (affected breast) is associated with Poland's syndrome.
- See Medical Policy Bulletin S-76 for guidelines on the removal of breast implants.
- Nipple tattooing (19499):
- When performed as part of a reconstructive procedure following radical surgery (e.g., mastectomy for benign or malignant disease).
- When performed following an injury (e.g., burn).
- Correction of inverted nipples (19355): When performed in attempt to restore the ability to breast feed.
- Mastectomy for gynecomastia (19300):
The American Society of Plastic Surgeons" classification system of gynecomastia is as follows:
Grade I: Small breast enlargement with localized button of tissue around the areola
Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest
Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy
Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast
Mastectomy for gynecomastia is considered reconstructive when the patient meets the criteria for Grade II, III, or IV; AND,
When pathologic gynecomastia (e.g., hypogonadism, endocrine disorders, metabolic disorders, neoplasms, and male breast cancer) and pharmacologic gynecomastia (i.e., gynecomastia induced by pharmacological agents, including but not limited to, cimetidine, digitalis, methadone, marijuana, clomiphene, chemotherapeutic agents, anti-retroviral agents, herbal remedies, chlorpromazine, and anabolic steroids) have been excluded.
- For boys 16, 17, and 18, whose body mass index (BMI) is less than the 75th percentile for age; i.e., a BMI of 22.7 for age 16, a BMI of 23.4 for age 17, and a BMI of 24.1 for age 18
- For men over age 18, a BMI of 25; AND,
If the above criteria are not met, it must be documented that the tissue is primarily breast tissue, by pathology report, and not just adipose (fatty) tissue.
Gynecomastia in patients <16 years of age generally will resolve on its own. Therefore, mastectomy for gynecomastia is not indicated for these patients and is considered cosmetic.
- 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 active acne. Cryotherapy performed for the treatment of active 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) by any method (e.g., by electrolysis (17380):
- When performed to prevent the recurrence of pilonidal cysts.
- When ingrown hairs are responsible for repeated painful cysts, targeted hair removal is appropriate.
- Electrolysis (17380) and laser hair removal (17999) performed for hirsutism are classified as cosmetic and not eligible for payment.
Hair Transplant (15775-15776): When performed as a result of injury or burn.
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.)
Port Wine Stain Treatment (17106-17108): For lesions on the face and neck. Treatment of lesions on the trunk or extremities is considered cosmetic.
- When post-traumatic (i.e. accident) nasal deformity exists or
- 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).
Rosacea Treatment (695.3)(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]): When functional impairment exists and pharmacologic therapy, specific for the treatment of rosacea, has failed or is contraindicated.
Scar Revision: When correcting scars and keloids resulting from an accident or when functional impairment exists.
Procedure Code Attachments
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.