Highmark Medical Policy Bulletin |
Section: | Surgery |
Number: | S-28 |
Topic: | Cosmetic Surgery vs. Reconstructive Surgery |
Effective Date: | January 28, 2002 |
Issued Date: | January 28, 2002 |
Date Last Reviewed: |
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.
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.
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. |
|
15770 | 15775 | 15776 | 15780 | 15781 | 15782 |
15783 | 15786 | 15787 | 15788 | 15789 | 15792 |
15793 | 15810 | 15811 | 15820 | 15821 | 15822 |
15823 | 15824 | 15825 | 15826 | 15828 | 15829 |
15831 | 15832 | 15833 | 15834 | 15835 | 15836 |
15837 | 15838 | 15839 | 17106 | 17107 | 17108 |
17340 | 17360 | 17380 | 19140 | 19318 | 19324 |
19325 | 19355 | 19499 | 20926 | 30400 | 30410 |
30420 | 30430 | 30435 | 30450 | 36468 | 36469 |
67900 | 67901 | 67902 | 67903 | 67904 | 67906 |
69300 | L8600 |
Traditional (UCR/Fee Schedule) 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. |
Comprehensive/Wraparound/PPO Guidelines
Managed Care (HMO/POS) Guidelines
Managed Care (Western Region Only)
|
PRN References |
[Version 002 of S-28] |
[Version 001 of S-28] |
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)
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 inc. |
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.]
CATEGORY A - NONCOVERED PROCEDURESPayment will not be made for the following procedures except on an inquiry basis. These procedures will be given individual consideration:
CATEGORY B - COVERED PROCEDURESSee 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.
Abdominal lipectomy (15831): When symptomatic diseaseconditions such as chronic pain, dermatitis, or ulceration created by the abdominal skin fold exist. |
Term | Description |
---|---|