Highmark Medical Policy Bulletin |
Section: | Surgery |
Number: | S-28 |
Topic: | Cosmetic Surgery vs. Reconstructive Surgery |
Effective Date: | May 31, 2004 |
Issued Date: | August 8, 2005 |
Date Last Reviewed: |
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.
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.
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. |
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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 | 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. 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. |
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
Managed Care
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PRN References 04/1993, Cryotherapy for the treatment of acne |
[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] |
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) |
Percentiles (Boys)
[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 noncovered procedures.
CATEGORY B - COVERED PROCEDURESSee 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:
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