Cosmetic Surgery vs. Reconstructive Surgery

Policy ID: S-28-038

Section: Surgery

Effective Date: November 01, 2018

Revised Date: April 28, 2022

Revision Effective Date: July 04, 2022

Last Reviewed: May 24, 2022

Applies To: Commercial and Medicaid Expansion

Description

Cosmetic surgery is performed to reshape normal structures of the body in order to improve the individual's appearance.

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.

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.

Physical functional impairment: In this policy, physical functional impairment means a limitation from normal (or baseline level) of physical functioning that may include, but is not limited to, problems with ambulation, mobilization, communication, respiration, eating, swallowing, vision, facial expression, skin integrity, distortion of nearby body part(s) or obstruction of an orifice.

Physical functional impairment excludes social, emotional and psychological impairments or potential impairments.

Criteria

Coverage is subject to the specific terms of the member’s benefit plan.

Panniculectomy 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
Documented inability to walk normally due to large overhanging pannus (pubic level or below); and
Documented chronic pain in lower back or in the pannus itself of six (6) months or more in duration; and
Documented inability to maintain proper hygiene in the lower abdominal/pubic areas resulting in ulceration, fungal dermatitis, cellulitis, folliculitis or infection caused by the abdominal skin fold.

Note:

After Significant Weight Loss Unrelated to Bariatric Surgery: In addition to the criteria listed above, there must be documentation that a stable weight has been maintained for six (6) months.
After Significant Weight Loss Following Bariatric Surgery: In addition to meeting criteria listed above there must documentation that a stable weight has been maintained for six months. *Generally, 12-18 months after surgery.

Panniculectomy is considered cosmetic and, therefore, non-covered for all other indications.

Procedure Codes

15830

17999

*Abdominoplasty is considered cosmetic and not a covered service.

Procedure Codes

15847

Clear High-Quality Color Photographs are required. Submit photos either through Availity portal or mail to BCBSND. (Faxed and black & white photos are not acceptable).

Upper Eyelid Blepharoplasty is considered medically necessary when ALL of the following criteria are met:

Documented complaints of interference with vision or visual field-related activities causing significant functional impact such as difficulty reading or driving due to upper eyelid skin drooping, looking through the eyelashes or seeing the upper eyelid skin; and
Any of the following:
- upper eyelid position contributes to difficulty tolerating a prosthesis in anophthalmic socket.
- redundant skin overhanging the upper eyelid margin and resting on the eyelashes or significant dermatitis on the upper eyelid caused by redundant tissue. This must be confirmed by photographs from the front and side (or sides) on which operation planned with the camera at eye level and the individual looking straight ahead (primary gaze)

AND

There is upper visual field loss of at least 20 degrees at rest, OR there is at least 30% improvement in the number of points seen in the upper field of vision when the upper lid is elevated by taping.

Procedure Codes

15820

15821

15822

15823

Upper Eyelid Blepharoptosis Repair is considered medically necessary when ALL of the following criteria are met:

Documented complaints of interference with vision or visual field-related activities such as difficulty reading or driving due to eyelid position; and
Photographs taken with the camera at eye level and the individual looking straight ahead, with documentation of the abnormal lid position (photos should be submitted for review); and
There is upper visual field loss of at least 20 degrees at rest, OR there is at least 30% improvement in the number of points seen in the upper field of vision when the upper lid is elevated by taping; and
The upper eyelid margin reflex distance 1 (MRD1) is less than or equal to 2.0 mm.

Procedure Codes

67901

67902

67903

67904

67906

67908

Brow Lift (Brow Ptosis Repair)

Brow lift (that is, repair of brow ptosis due to laxity of the forehead muscles) is considered medically necessary when ALL of the following criteria are met:

Brow ptosis is causing a functional impairment of upper/outer visual fields with documented complaints of interference with vision or visual field related activities such as difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin; and
Photographs show the eyebrow below the supraorbital rim; and
There is at least 30% improvement in the number of points seen in the upper field of vision when the upper lid is elevated by taping.

Procedure Codes

67900

When bilateral blepharoplasty or repair of ptosis is requested or performed for a bilateral lid dysfunction where only one eye meets the above criteria, and the contralateral eye, although also affected, does not quite meet criteria, a bilateral procedure may be considered medically necessary based on Hering’s law of equal innervation.

Blepharoplasty, lower lid may be considered medically necessary for reconstructive repair where there is functional visual impairment due to any 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; or
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 required to be documented by preoperative photographs that must be available upon request. Photographs must include one view looking up and one looking down and demonstrate the functional deficit; and
Functional impairment including BOTH of the following:
- Documented uncontrolled tearing or irritation; and
- Conservative treatments tried and failed.

Note: When the physician has determined that the individual 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 are considered cosmetic and, therefore, non-covered when the above medical necessity is not met.

Procedure Codes

15820

15821

15822

15823

67900

67901

67902

67903

67904

67906

67908

67909

67911

Canthopexy may be considered medically necessary when performed for ANY ONE 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 is considered cosmetic and, therefore, non-covered when the above medical necessity is not met.

Procedure Codes

21280

21282

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

Reduction mammaplasty may be considered medically necessary when clinical documentation shows AT LEAST two (2) of the following symptoms:

Muscle strain, such as backache, neck pain, shoulder pain, headache, and/or upper extremity peripheral neuropathy
Postural change with a tendency toward dorsal kyphosis
Problems associated with breast weight and brassiere support, such as clavicular bra strap grooves
Hygiene problems, such as intertrigo or exacerbation of acne and hidradenitis suppurativa
Limitations of normal activity, such as inability to participate in exercise and sports
Difficulty sleeping or breathing due to weight of the breasts

Reduction mammoplasty/breast reduction are considered cosmetic and, therefore, non-covered when the above medical necessity is not met.

The written request must include:

A summary of the history and physical examination of the individual. The physical examination should document the diagnosis of symptomatic breast hypertrophy based on the symptomatology. The diagnosis of breast hypertrophy involves a comparison of overall body stature with breast size as determined by the relative volume of breast tissue.
The breast should be free of evidence of breast cancer and any physical abnormality should be appropriately evaluated prior to surgery.
The symptoms of female symptomatic breast hypertrophy and their frequency can be quantified using validated, structured questionnaires that encompass both physical and psychosocial symptoms.
Estimation of breast tissue to be removed that would alleviate symptoms. Please reference the Schnur guidelines located at bottom of this medical policy

*Repeat reduction mammoplasty/breast reduction requests will be reviewed by the Medical Director for individual consideration.

* Must be 18 years of age to qualify for a reduction mammoplasty/breast reduction.

Benefits for reduction mammoplasty following contralateral mastectomy will be allowed as part of a reconstructive sequence to achieve symmetry. Precertification is not necessary nor is a minimum number of grams required.

Procedure Codes

19318

19499

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

Augmentation mammoplasty is considered cosmetic and, therefore, non-covered when the above medical necessity is not met.

NOTE: Surgery on an unaffected breast in order to provide symmetry with a breast on which a mastectomy and reconstructive procedure have been performed may be considered medically necessary.

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.

Procedure Codes

19325

19499

L8600

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 are considered cosmetic and, therefore, non-covered for any other indication

Procedure Codes

11920

11921

19350

19499

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 are considered cosmetic and, therefore, non-covered for any other indication.

Procedure Codes

19355

Mastectomy for gynecomastia

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

The individual meets the criteria for Grade II, III, or IV; and
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 Less than or equal to 25; and
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, services may be considered medically necessary when it is documented that the tissue is primarily breast tissue, by pathology report, and not just adipose (fatty) tissue.

NOTE: Gynecomastia in individuals less than 16 years of age generally will resolve on its own. Therefore, mastectomy for gynecomastia is not indicated for these individuals and is considered cosmetic.

Mastectomy for gynecomastia is considered cosmetic and, therefore, non-covered for any other indication.

Procedure Codes

19300

Vulvectomy 56620, 56625 and Labiaplasty 15839

*If the intended service relates to transgender care, please refer to the BCBSND Corporate Medical Policy Gender Affirmation Surgery.

Labiaplasty, Vulvectomy, Vulvoplasty may be medically necessary for 18 years and older and ANY of the following:

A congenital anomaly causing physical functional impairment.
Medical diagnosis of cancer affecting the area.
The area is affected by chronic and/or recurrent infection or chronic irritation that is not resolved with conservative therapy (ex: personal hygiene and avoidance of form-fitting clothes).
Physical functional impairment caused by trauma/injury/previous therapeutic procedures or surgery; or severe anatomic variants; or chemotherapy.
Physical functional impairment that interferes with instrumental ADLs and is not resolved with conservative treatment (Instrumental ADLs: Activities that are required for an individual to effectively work in their profession {e.g., dance instructor, professional dancer, jockey}).

*The request must include documented evidence of significant functional impairment and the expected functional improvement following correction of physical impairment.

If the functional impairment is solely for sexual dysfunction or to enhance sexual performance, procedures are a benefit plan exclusion and not eligible for coverage unless coverage for treatment of sexual dysfunction is specifically stated as a benefit in the individual’s specific benefit plan booklet.

Procedure Codes

56620

56625

15839

Cryotherapy (e.g., Cryosurgery) may be considered medically necessary when performed for diagnoses other than active acne.

Cryotherapy performed for the treatment of active acne are considered cosmetic and, therefore, non-covered.

Procedure Codes

17000

17003

17004

17340

67825

Chemical Exfoliation for Acne may be considered medically necessary when performed to treat individuals with active acne that has failed a trial of topical and/or oral antibiotic acne therapy.

Epidermal chemical peels used to treat acne scarring or dermal peels used to treat end-state acne scarring are considered cosmetic.

Procedure Codes

17360

Dermabrasion

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

Dermabrasion is considered cosmetic and therefore, non-covered for any other indication

Procedure Codes

15780

15781

15782

15783

15786

15787

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 considered cosmetic and, therefore, non-covered.

Procedure Codes

12011

12051

13151

Hair Removal (Permanent) by any method (e.g., by electrolysis) may be considered medically necessary when BOTH 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, therefore, not covered.

Hair removal is considered cosmetic and, therefore, non-covered for any other indication

Procedure Codes

17380

17999

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

Hair transplant is considered cosmetic and, therefore, non-covered for any other indication.

Procedure Codes

15220

15221

15775

15776

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 is considered cosmetic and, therefore, non-covered for any other indication.

Procedure Codes

69300

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 may be considered medically necessary for individuals under the age of 18.

Treatment of port wine stains on the trunk or extremities is considered cosmetic and, therefore, non-covered for individuals 18 years and older.

Procedure Codes

17106

17107

17108

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 is considered cosmetic and, therefore, non-covered for any other indication.

Procedure Codes

30400

30410

30420

30430

30435

30450

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 is considered cosmetic and, therefore, non-covered for any other indication.

Procedure Codes

15824

15825

15826

15828

15829

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 is considered cosmetic and, therefore, non-covered for any other indication.

Procedure Codes

17999

96900

Scar Revision

Scar tissue forms as skin heals after an injury (such as an accident) or surgery. The amount of scarring may be determined by the size, depth, and location of the wound; the age of the person; heredity; and skin characteristics including color (pigmentation). Excision or revision of the scar may be necessary when improper healing has occurred.

Scar excision / revision is eligible for coverage in the follow circumstances:

Scars caused by accidental injuries.
Scars related to or following a covered surgery or trauma

A scar excision / revision that does not meet the two (2) indications outlined above may be eligible if functional impairment is caused by the scar.

Functional. Impairment is defined, for purposes of this policy, as a structural change in the affected body part which prohibits the normal or special action of that body part.

Symptoms such as intertrigo, itching, irritation or tenderness caused by the scar are medical conditions for which scar revision is considered medically necessary.

Scar excision / revision is considered COSMETIC when the scar was the result of a prior cosmetic procedure that was not performed to treat an injury or illness. Examples include tattoos and body piercing.

Members must consult their applicable benefit plans or contact a member services representative for specific coverage information.

Other Procedures

The following services are always considered Cosmetic and are a Benefit Plan Exclusions under all BCBS ND Plans. The absence of a service from this list does not mean that the service is not cosmetic:

Chemical peel (CPT: 15788, 15789, 15792, 15793)
- When used to treat photoaged skin, wrinkles or acne scarring or dermal peels used to treat end-state acne scarring.

Correction of diastasis recti abdominis
Micro needling, collagen induction therapy, or derma rolling
Collagen injections (CPT: 11950, 11951, 11952, 11954)
Microdermabrasion
Body piercing of any site, and repair of any sequela of piercing.
Repair or reversal of any body modification procedure (e.g. repair of stretched earlobe)
Suction assisted lipectomy (CPT: 15876, 15877, 15878, 15879)
Excision, excessive skin, thigh, leg, hip, buttock, arm, forearm, or hand, submental fat pad, other area.
Abdominoplasty (CPT:15847)
Brachioplasty (CPT: 15836)
Cervicoplasty (CPT: 15819, 15838)
Thighplasty (CPT: 15832, 15833, 15834, 15835)
Genioplasty (CPT: 21120, 21121, 21122, 21123)
Cryolipolysis / Coolsculpting
Reduction Thyroid Chondroplasty
Tattoo Removal
Testicular prosthesis (CPT 54660)
Mastopexy
Procedures/products/services via any treatment modality (e.g., laser, cryotherapy) performed solely for the treatment of post-acne scarring
Salabrasion
Temporary hair removal (e.g., waxing, laser)
Topical retinoid or anti-acne products when used for any of the following
- Fine lines and/or wrinkles of the face
- Hyperpigmentation, facial mottling of skin
- Melasma
- Solar lentigo (lentigines)
- Dermatoheliosis
- “sun damage”
- Angti-aging use
- Facial Roughness

Procedure Codes

15788

15789

15792

15793

15832

15833

15834

15835

15836

15837

15838

15839

15876

15877

15878

15879

17340

17999

19316

36468

G0429

Q2026

Q2028

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.

Diagnosis Codes

Not Applicable

S -28 Additional Documentation

Minimum Weight of Breast Tissue Removed per Breast, as a Function of Body Surface Area

Schnur Sliding Scale

Body Surface Area (in meters squared)

Minimum weight of tissue to be removed per breast (grams)

1.35

199

1.40

218

1.45

238

1.50

260

1.55

284

1.60

310

1.65

338

1.70

370

1.75

404

1.80

441

1.85

482

1.90

527

1.95

575

2.00

628

2.05

687

2.10

750

2.15

819

2.20

895

2.25

978

2.30 or greater

> = 1000

The American Society of Plastic Surgeons' classification system of gynecomastia is as follows:

Grade I:

Small breast enlargement with localized button of tissue around the areola

Grade II:

Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest

Grade III:

Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy

Grade IV:

Marked breast enlargement with skin redundancy and feminization of the breast

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020 Revisions to Blepharoplasty-criteria revised, abdominoplasty-determined cosmetic, panniculectomy-documentation criteria added and Note regarding significant weight loss, port wine stains-added age criteria, reduction mammoplasty-added statement regarding repeat requests)

Internal Medical Policy Committee 9-21-2020 Draft policy for provider input

Internal Medical Policy Committee 1-19-2021 Removed 17110, 17111, 20912, and adjusted language

Medical Review 3-2-2021 Additional information and procedure codes added

Internal Medical Policy Committee 5-20-2021 updating language.

Internal Medical Policy Committee 5-24-2022 Revision, added clarifying statements and coding specific to North Dakota

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-28-037

Section: Surgery

Effective Date: November 01, 2018

Revised Date: June 04, 2021

Revision Effective Date: July 05, 2021

Last Reviewed: May 20, 2021

Archived Date: July 03, 2022

Applies To: Commercial and Medicaid Expansion

Description

Cosmetic surgery is performed to reshape normal structures of the body in order to improve the individual's appearance.

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.

Criteria

Coverage is subject to the specific terms of the member’s benefit plan.

Panniculectomy 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
Documented inability to walk normally due to large overhanging pannus (pubic level or below); and
Documented chronic pain in lower back or in the pannus itself of 6 months or more in duration; and
Documented inability to maintain proper hygiene in the lower abdominal/pubic areas resulting in ulceration, fungal dermatitis, cellulitis, folliculitis or infection caused by the abdominal skin fold.

Note:

After Significant Weight Loss Unrelated to Bariatric Surgery: In addition to the criteria listed above, there must be documentation that a stable weight has been maintained for six months.
After Significant Weight Loss Following Bariatric Surgery: In addition to meeting criteria listed above there must documentation that a stable weight has been maintained for six months. *Generally, 12-18 months after surgery.

Panniculectomy is considered cosmetic and, therefore, non-covered for all other indications.

Procedure Codes

15830

17999

*Abdominoplasty is considered cosmetic and not a covered service.

Procedure Codes

15847

Clear High-Quality Color Photographs are required. Submit photos either through Availity portal or mail to BCBSND. (Faxed and black & white photos are not acceptable).

Upper Eyelid Blepharoplasty is considered medically necessary when ALL of the following criteria are met:

Documented complaints of interference with vision or visual field-related activities causing significant functional impact such as difficulty reading or driving due to upper eyelid skin drooping, looking through the eyelashes or seeing the upper eyelid skin; and
Any of the following:
- upper eyelid position contributes to difficulty tolerating a prosthesis in anophthalmic socket.
- redundant skin overhanging the upper eyelid margin and resting on the eyelashes or significant dermatitis on the upper eyelid caused by redundant tissue. This must be confirmed by photographs from the front and side (or sides) on which operation planned with the camera at eye level and the individual looking straight ahead (primary gaze)

AND

There is upper visual field loss of at least 20 degrees at rest, OR there is at least 30% improvement in the number of points seen in the upper field of vision when the upper lid is elevated by taping.

Procedure Codes

15820

15821

15822

15823

Upper Eyelid Blepharoptosis Repair is considered medically necessary when ALL of the following criteria are met:

Documented complaints of interference with vision or visual field-related activities such as difficulty reading or driving due to eyelid position; and
Photographs taken with the camera at eye level and the individual looking straight ahead, with documentation of the abnormal lid position (photos should be submitted for review); and
There is upper visual field loss of at least 20 degrees at rest, OR there is at least 30% improvement in the number of points seen in the upper field of vision when the upper lid is elevated by taping; and
The upper eyelid margin reflex distance 1 (MRD1) is less than or equal to 2.0 mm.

Procedure Codes

67901

67902

67903

67904

67906

67908

Brow Lift (Brow Ptosis Repair)

Brow lift (that is, repair of brow ptosis due to laxity of the forehead muscles) is considered medically necessary when ALL of the following criteria are met:

Brow ptosis is causing a functional impairment of upper/outer visual fields with documented complaints of interference with vision or visual field related activities such as difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin; and
Photographs show the eyebrow below the supraorbital rim; and
There is at least 30% improvement in the number of points seen in the upper field of vision when the upper lid is elevated by taping.

Procedure Codes

67900

Blepharoplasty, lower lid may be considered medically necessary for reconstructive repair where there is functional visual impairment due to any 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; or
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 required to be documented by preoperative photographs that must be available upon request. Photographs must include one view looking up and one looking down and demonstrate the functional deficit; and
Functional impairment including BOTH of the following:
- Documented uncontrolled tearing or irritation; and
- Conservative treatments tried and failed.

Blepharoplasty, brow lift, and blepharoptosis are considered cosmetic and, therefore, non-covered when the above medical necessity is not met.

Procedure Codes

15820

15821

15822

15823

67900

67901

67902

67903

67904

67906

67908

67909

67911

Canthopexy may be considered medically necessary when performed for ANY ONE 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 is considered cosmetic and, therefore, non-covered when the above medical necessity is not met.

Procedure Codes

21280

21282

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

Reduction mammaplasty may be considered medically necessary when clinical documentation shows AT LEAST two (2) of the following symptoms:

Muscle strain, such as backache, neck pain, shoulder pain, headache, and/or upper extremity peripheral neuropathy
Postural change with a tendency toward dorsal kyphosis
Problems associated with breast weight and brassiere support, such as clavicular bra strap grooves
Hygiene problems, such as intertrigo or exacerbation of acne and hidradenitis suppurativa
Limitations of normal activity, such as inability to participate in exercise and sports
Difficulty sleeping or breathing due to weight of the breasts

Reduction mammoplasty/breast reduction are considered cosmetic and, therefore, non-covered when the above medical necessity is not met.

The written request must include:

A summary of the history and physical examination of the individual-The physical examination should document the diagnosis of symptomatic breast hypertrophy based on the symptomatology. The diagnosis of breast hypertrophy involves a comparison of overall body stature with breast size as determined by the relative volume of breast tissue.
The breast should be free of evidence of breast cancer and any physical abnormality should be appropriately evaluated prior to surgery.
The symptoms of female symptomatic breast hypertrophy and their frequency can be quantified using validated, structured questionnaires that encompass both physical and psychosocial symptoms.
Estimation of breast tissue to be removed that would alleviate symptoms. Please reference the Schnur guidelines located at bottom of this medical policy.

*Repeat reduction mammoplasty/breast reduction requests will be reviewed by the Medical Director for individual consideration.

Procedure Codes

19318

19499

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

Augmentation mammoplasty is considered cosmetic and, therefore, non-covered when the above medical necessity is not met.

NOTE: Surgery on an unaffected breast in order to provide symmetry with a breast on which a mastectomy and reconstructive procedure have been performed may be considered medically necessary.

Procedure Codes

19325

19499

L8600

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 are considered cosmetic and, therefore, non-covered for any other indication

Procedure Codes

11920

11921

19350

19499

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 are considered cosmetic and, therefore, non-covered for any other indication.

Procedure Codes

19355

Mastectomy for gynecomastia

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

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

Mastectomy for gynecomastia is considered cosmetic and, therefore, non-covered for any other indication.

Procedure Codes

19300

Cryotherapy (e.g. Cryosurgery) may be considered medically necessary when performed for diagnoses other than active acne.

Cryotherapy performed for the treatment of active acne are considered cosmetic and, therefore, non-covered.

Procedure Codes

17000

17003

17004

17340

67825

Chemical Exfoliation for Acne may be considered medically necessary when performed to treat individuals with active acne that has failed a trial of topical and/or oral antibiotic acne therapy.

Epidermal chemical peels used to treat acne scarring or dermal peels used to treat end-state acne scarring are considered cosmetic.

Procedure Codes

17360

Dermabrasion

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

Dermabrasion is considered cosmetic and therefore, non-covered for any other indication.

Procedure Codes

15780

15781

15782

15783

15786

15787

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 considered cosmetic and, therefore, non-covered.

Procedure Codes

12011

12051

13151

Hair Removal (Permanent) by any method (e.g., by electrolysis) may be considered medically necessary when BOTH 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, therefore, not covered.

Hair removal is considered cosmetic and, therefore, non-covered for any other indication

Procedure Codes

17380

17999

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

Hair transplant is considered cosmetic and, therefore, non-covered for any other indication.

Procedure Codes

15220

15221

15775

15776

Otoplasty is considered cosmetic and, therefore, non-covered for any other indication.

Procedure Codes

69300

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 may be considered medically necessary for individuals under the age of 18.

Treatment of port wine stains on the trunk or extremities is considered cosmetic and, therefore, non-covered for individuals 18 years and older.

Procedure Codes

17106

17107

17108

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 is considered cosmetic and, therefore, non-covered for any other indication.

Procedure Codes

30400

30410

30420

30430

30435

30450

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 is considered cosmetic and, therefore, non-covered for any other indication.

Procedure Codes

15824

15825

15826

15828

15829

Rosacea treatment is considered cosmetic and, therefore, non-covered for any other indication.

Procedure Codes

17999

96900

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

Scar revision treatment is considered cosmetic and, therefore, non-covered for any other indication.

Other Procedures

The following services are always considered Cosmetic and are a Benefit Plan Exclusions under all BCBS ND Plans. The absence of a service from this list does not mean that the service is not cosmetic:

Chemical peel (CPT: 15788, 15789, 15792, 15793)
- When used to treat photoaged skin, wrinkles or acne scarring or dermal peels used to treat end-state acne scarring.

Correction of diastasis recti abdominis
Micro needling, collagen induction therapy, or derma rolling
Collagen injections (CPT: 11950, 11951, 11952, 11954)
Microdermabrasion
Body piercing of any site, and repair of any sequela of piercing.
Repair or reversal of any body modification procedure (e.g. repair of stretched earlobe)
Suction assisted lipectomy (CPT: 15876, 15877, 15878, 15879)
Excision, excessive skin, thigh, leg, hip, buttock, arm, forearm, or hand, submental fat pad, other area.
Abdominoplasty (CPT:15847)
Brachioplasty (CPT: 15836)
Cervicoplasty (CPT: 15819, 15838)
Thighplasty (CPT: 15832, 15833, 15834, 15835)
Genioplasty (CPT: 21120, 21121, 21122, 21123)
Cryolipolysis / Coolsculpting
Reduction Thyroid Chondroplasty
Tattoo Removal
Testicular prosthesis (CPT 54660)
Mastopexy
Procedures/products/services via any treatment modality (e.g., laser, cryotherapy) performed solely for the treatment of post-acne scarring
Salabrasion
Temporary hair removal (e.g., waxing, laser)
Topical retinoid or anti-acne products when used for any of the following
- Fine lines and/or wrinkles of the face
- Hyperpigmentation, facial mottling of skin
- Melasma
- Solar lentigo (lentigines)
- Dermatoheliosis
- “sun damage”
- Angti-aging use
- Facial Roughness

Procedure Codes

15788

15789

15792

15793

15832

15833

15834

15835

15836

15837

15838

15839

15876

15877

15878

15879

17340

17999

19316

36468

G0429

Q2026

Q2028

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.

Diagnosis Codes

Not Applicable

S -28 Additional Documentation

Minimum Weight of Breast Tissue Removed per Breast, as a Function of Body Surface Area

Schnur Sliding Scale

Body Surface Area (in meters squared)

Minimum weight of tissue to be removed per breast (grams)

1.35

199

1.40

218

1.45

238

1.50

260

1.55

284

1.60

310

1.65

338

1.70

370

1.75

404

1.80

441

1.85

482

1.90

527

1.95

575

2.00

628

2.05

687

2.10

750

2.15

819

2.20

895

2.25

978

2.30 or greater

> = 1000

The American Society of Plastic Surgeons” classification system of gynecomastia is as follows:

Grade I:

Small breast enlargement with localized button of tissue around the areola

Grade II:

Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest

Grade III:

Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy

Grade IV:

Marked breast enlargement with skin redundancy and feminization of the breast

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-21-2020 Draft policy for provider input

Internal Medical Policy Committee 1-19-2021 Removed 17110, 17111, 20912, and adjusted language

Medical Review 3-2-2021 Additional information and procedure codes added

Internal Medical Policy Committee 5-20-2021 updating language.

Links

References (PDF)

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