Highmark Medical Policy Bulletin |
Section: | Surgery |
Number: | S-28 |
Version: | 022 |
Topic: | Cosmetic Surgery vs. Reconstructive Surgery |
Effective Date: | April 2, 2012 |
Issued Date: | June 18, 2012 |
Date Last Reviewed: | 05/2012 |
Indications and Limitations of Coverage
Cosmetic Surgery Cosmetic surgery is performed to improve an individual's appearance. A cosmetic or reconstructive procedure or surgery done to improve the appearance of any portion of the body or performed for psychological or psychosocial reasons is generally not covered when there is no improvement in physiological function expected, except for the following:
Reconstructive Surgery 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 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. |
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15775 | 15776 | 15780 | 15781 | 15782 | 15783 |
15786 | 15787 | 15788 | 15789 | 15792 | 15793 |
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 | 19316 | 19318 |
19324 | 19325 | 19355 | 19499 | 21280 | 21282 |
30400 | 30410 | 30420 | 30430 | 30435 | 30450 |
36468 | 36469 | 67900 | 67901 | 67902 | 67903 |
67904 | 67906 | 69300 | 96900 | G0429 | L8600 |
Q2026 | Q2027 |
Traditional (UCR/Fee Schedule) Guidelines
Reconstructive Surgery/Covered:
Cosmetic Surgery/Not 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
PRN
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 Venereol, 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 |
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.
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) preoperative photographs document that the panniculus or fold hangs at or below the level of the symphysis 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.
Blepharoplasty (15820-15823), Brow lift, and Blepharoptosis(67900-67906): When visual impairment is documented by:
Canthopexy (21280, 21282): When performed for the following conditions:
Breast Surgery :
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):
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. Rhinoplasty (30400-30450):
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. |