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.

Abdominoplasty, Panniculectomy (Tummy Tuck) may be considered medically necessary when ALL of the following criteria are met:

• Preoperative photographs document that the panniculus or fold hangs at or below the level of the symphysis pubis; and
• 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 (including appropriate prescription medications) over a period of three (3) months.

NOTE: The patient must be 18 months postoperative following bariatric surgery.

All other indications for abdominoplasty and/or panniculectomy are considered cosmetic and, therefore, not covered.

Blepharoplasty, Brow lift, and Blepharoptosis may be considered medically necessary for ANY of the following conditions:

• 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; or
• The upper eyelid skin rests on the eyelashes; or
• The upper eyelid indicates the presence of dermatitis; or
• The upper eyelid position contributes to difficulty tolerating a prosthesis in an ophthalmic socket; or
• The brow position is below the superior orbital rim; or
• Entropian (eyelashes turning under).

AND

When ALL of the following criteria are met:

• The impairment is documented by preoperative photographs, maintained in the patient's records, including one view of the patient in primary position, one view looking up and one looking down and demonstrate the functional deficit; and
• An automated visual field study was done except for upper eyelid dermatitis, ocular prosthesis problem, and entropian and results interpreted by the provider for the following functional deficits:
  • Visual impairment due to dermatochalasis when the upper eyelid margin within 2.5 mm (1/4 of the diameter of the visible iris) of the corneal light reflex (MRD less than or equal to 2.5 mm), with patient in primary gaze: or
  • The brow position is below the superior orbital rim; and
• A statement is submitted from the provider regarding the visual field study with documentation of taped and untaped automated visual field testing confirming 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.

Blepharoplasty, lower lid may be considered medically necessary for reconstructive repair where there is functional visual impairment due to ONE of the following conditions:

• Ectropion, entropion, or epiblepharon repair for corneal and/ or conjunctival injury; or
• Disease due to ectropion, entropion, trichiasis, or epiblepharon; or
• Poor eyelid tone (with or without entropion) that causes lid retraction and/or exposure;
• Keratoconjunctivitis often resulting in epiphora; or
• Lower eyelid edema due to a metabolic or inflammatory disorder when the edema is causing a persistent visual impairment (e.g., secondary to systemic corticosteroid therapy, myxedema, Grave's disease, nephrotic syndrome) and is unresponsive to conservative medical management.

AND

• The impairment is documented by preoperative photographs, maintained in the patient's records, including one view of the patient in primary position, one view looking up and one looking down and demonstrate the functional deficit; and
• Functional impairment including ALL of the following:
  • Documented uncontrolled tearing or irritation; and
  • Conservative treatments tried and failed.

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.

Blepharoplasty, Brow lift, and Blepharoptosis that does not meet medical necessity criteria above are considered cosmetic and, therefore, not covered.

Canthopexy, may be considered medically necessary when performed for ANY of the following conditions:

• Presence of corneal or conjunctival staining; or
• Mucous membrane changes; or
• Documentation of epiphora and poor closure of the lids; or
• Entropion; or
• Ectropion; or
• Bell's palsy; or
• Dermatochalasis.

Canthopexy that do not meet the medical necessity criteria above are considered cosmetic and, therefore, not covered.

Reduction mammoplasty/breast reduction may be considered medically necessary when ALL of the following criteria are met:

• The patient has at least a 1-year history of significant signs and symptoms that interfere with normal activities, including at least 2 of the following:
  • Back, neck or shoulder pain not related to other causes such as arthritis, poor posture, acute strains, etc.; or
  • Clinical, non-seasonal submammary intertrigo; or
  • Significant shoulder grooving or shoulder point tenderness; or
  • Breast hypertrophy; or
  • Paresthesias of hands/arms; and
• Conservative measures, such as those below, have been tried and have not resulted in significant improvement:
  For back, neck, or shoulder pain, at least 3 months of conservative treatment including;
  • Appropriate support bra; and
  • Non-steroidal, anti-inflammatory drugs (NSAIDS) (if not contraindicated); and
  • Exercises and heat or cold application; and
• For chronic submammary intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing), at least 3 months of conservative therapy including:
  • Appropriate hygiene; and
  • Appropriate medical treatment (including appropriate prescription medications); and
  • Utilization of an appropriate support bra; and
• Candidates for breast reduction must be greater than or equal to 18 years of age. Requests for patient under 18 years old will be considered on an individual basis, due to the sensitive nature of performing procedure on the developing breast, and
• Average weight of tissue planned to be removed in each breast is above the 22nd percentile as referenced on the Schnur Sliding Scale based on the individual’s body surface area (BSA).

The appropriate amounts (in grams) of breast tissue must be anticipated for removal from at least one breast, which is based on the individual's total body surface area (BSA) in meters squared.

Reduction mammoplasty performed solely to remove fat and/or skin, but not the minimum specimen weight of breast tissue outlined above, is considered not medically necessary and, therefore, not covered.

If preferred, there are several websites with calculators to assist in calculating body surface area, an example is http://www.globalrph.com/bsa2.htm.

Please see the table attachment at the end of the policy for the Schnur Table.

Augmentation mammoplasty may be considered medically necessary when ANY of the following criteria are met:

• When unilateral breast aplasia is present; or
• Following extirpative surgery for benign disease (e.g., subcutaneous mastectomy with either immediate or delayed [second stage] prosthesis); or
• When a reconstructive procedure is performed following previous radical surgery for malignant disease.

NOTE: 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 implantable breast prosthesis 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 will be denied as cosmetic.

• When breast hypoplasia (affected breast) is associated with Poland's syndrome.

Augmentation mammoplasty performed for any other indication is considered cosmetic and, therefore, not covered.

Nipple tattooing may be considered medically necessary when ANY of the following criteria are met:

• When performed as part of a reconstructive procedure following radical surgery (e.g., mastectomy for benign or malignant disease); or
• When performed following an injury (e.g., burn).

Nipple tattooing for any other indication is considered cosmetic and, therefore, not covered.

Correction of inverted nipples may be considered medically necessary when performed in an attempt to restore the ability to breast feed.

Correction of inverted nipples for any other indication is considered cosmetic and, therefore, not covered.

Mastectomy for gynecomastia
Mastectomy for gynecomastia is considered reconstructive when ALL of the following criteria are met:

1. The patient meets the criteria for Grade II, III, or IV; and

2. One of the following:

• For boys 16, 17, and 18 years old, 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, or
• For men over age 18, and a BMI of ≤ 25; and

3. 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.

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.

NOTE: Gynecomastia in patients less than16 years of age generally will resolve on its own. Therefore, mastectomy for gynecomastia is not indicated for these patients and is considered cosmetic.

Mastectomy for gynecomastia for any other indication is considered cosmetic and, therefore, not covered.

Cryotherapy may be considered medically necessary 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 may be considered medically necessary when correcting defects resulting from an accident or when functional impairment exists.

Dermabrasion for any other indication is considered cosmetic and, therefore, not covered.

Earlobe Surgery may be considered medically necessary when repairing an earlobe defect if the defect is a through and through laceration resulting in a bilobe earlobe.

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 may be considered medically necessary when ALL of the following criteria are met:

• When performed to prevent the recurrence of pilonidal cysts; and
• When ingrown hairs are responsible for repeated painful cysts, targeted hair removal is appropriate.

NOTE: Electrolysis and laser hair removal performed for hirsutism is classified as cosmetic and not eligible for payment.

Hair removal for any other indication is considered cosmetic and, therefore, not covered.

Hair Transplant may be considered medically necessary when performed as a result of injury or burn.

Hair transplant for any other indication is considered cosmetic and, therefore, not covered.

Otoplasty may be considered medically necessary 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.)

Otoplasty for any other indication is considered cosmetic and, therefore, not covered.

Port Wine Stain Treatment may be considered medically necessary for port wine stains on the face and neck.

Treatment of port wine stains on the trunk or extremities is considered cosmetic and not covered.

Rhinoplasty may be considered medically necessary when ANY of the following criteria are met:

• When post-traumatic (i.e., accident) nasal deformity exists; or
• When functional breathing impairment is present.

Rhinoplasty for any other indication is considered cosmetic and, therefore, not covered.

Rhytidectomy (meloplasty, face lift) may be considered medically necessary when functional impairment exists as a result of a disease state (e.g., facial paralysis).

Rhytidectomy for any other indication is considered cosmetic and, therefore, not covered.

Rosacea 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]) may be considered medically necessary when:

• Functional impairment exists and pharmacologic therapy, specific for the treatment of rosacea, has failed or is contraindicated.

Rosacea treatment for any other indication is considered cosmetic and, therefore, not covered.

Scar Revision may be considered medically necessary when correcting scars and keloids resulting from an accident or when functional impairment exists.

Scar revision for any other indication is considered cosmetic and, therefore, not covered.

Other Procedures

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.

• Chemical exfoliation for acne
• Chemical peel
• Correction of diastasis recti abdominis
• Excision, excessive skin, thigh, leg, hip, buttock, arm, forearm, or hand, submental fat pad, other area.
• Mastopexy
• Microdermabrasion
• Procedures/products/services via any treatment modality (e.g., laser, cryotherapy) performed solely for the treatment of post-acne scarring
• Salabrasion 
• Suction assisted lipectomy done solely for cosmetic purposes 
• Temporary hair removal (e.g., waxing, laser)

Corrective facial surgery will be considered cosmetic rather than reconstructive when there is not any functional impairment present.

An indication or a diagnosis of pain may qualify as functional impairment.

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 who 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.

See additional documentation attachment.

See Medical Policy Bulletin G-20 for actinic keratosis.

See Medical Policy Bulletin S-36 for removal of skin lesions.

See Medical Policy Bulletin S-45 for repair of lacerations.

See Medical Policy Bulletin S-55 for surgical treatment of varicose veins.

See Medical Policy Bulletin S-74 for covered suction assisted lipectomy services.

See Medical Policy Bulletin S-129 for mastectomy and reconstructive surgery.

See Medical Policy Bulletin S-184 for gender reassignment surgery.

Cosmetic or reconstructive surgery is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

A network provider can bill the member for the non-covered service.

• Link to Table Attachment(s)

• Link to References