Highmark Medical Policy Bulletin |
Section: | Surgery |
Number: | S-28 |
Topic: | Cosmetic Surgery vs. Reconstructive Surgery |
Effective Date: | March 17, 2008 |
Issued Date: | March 17, 2008 |
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 | 15830 |
15832 | 15833 | 15834 | 15835 | 15836 | 15837 |
15838 | 15839 | 15847 | 15876 | 15877 | 15878 |
15879 | 17000 | 17003 | 17004 | 17106 | 17107 |
17108 | 17340 | 17360 | 17380 | 17999 | 19300 |
19318 | 19324 | 19325 | 19355 | 19499 | 30400 |
30410 | 30420 | 30430 | 30435 | 30450 | 36468 |
36469 | 67900 | 67901 | 67902 | 67903 | 67904 |
67906 | 69300 | 96900 | L8600 |
Traditional (UCR/Fee Schedule) Guidelines
Reconstructive Surgery/Covered:
Cosmetic Surgery/Not covered:
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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 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:
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. |
PRN References 04/1993, Cryotherapy for the treatment of acne |
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
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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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