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.

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

*Abdominoplasty is considered cosmetic and not a covered service.

Procedure Codes

Blepharoplasty, Brow lift, and Blepharoptosis may be considered medically necessary for ANY of the following conditions:

• The upper eyelid margin within 2.0 mm (1/4 of the diameter of the visible iris) of the corneal light reflex (MRD less than 2.0 mm), with individual in primary gaze; or
• The upper eyelid skin rests on the eyelashes; or
• The upper eyelid indicates the presence of dermatitis; or
• The upper eyelid position contributes to difficulty tolerating a prosthesis in an ophthalmic socket; or
• The brow position is below the superior orbital rim; or
• Entropian (eyelashes turning under);

AND

Upper Eyelid Blepharoplasty for the following indications may be considered medically necessary when ANY of the above are met AND:

• Diagnosis of blepharochalasis, dermatochalasis or pseudoptosis
• With upper visual field loss of at least 20 degrees or 30% on visual field testing that is corrected when the upper lid margin is elevated by taping the eyelid

Procedure Codes

Upper Eyelid Blepharoptosis Repairmay be considered medically necessary when ANY of the above are met AND:

• There is upper visual field loss of at least 20 degrees or 30% on visual field testing that is corrected when the upper lid margin is elevated by taping the eyelid
• The upper eyelid margin reflex distance 1 (MRD1) is ≤ 2.0 mm

Procedure Codes

Brow Lift is considered medically necessary when ANY of the above are met and ALL of the following criteria are met:

• The brow position is below the superior orbital rim
• Individual complains of interference with vision or visual field, difficulty reading due to upper eyelid drooping, looking through eyelashes or seeing upper eyelid skin
• Upper visual field loss of at least 20 degrees or 30% on visual field testing that cannot be corrected by upper lid blepharoplasty

Procedure Codes

COLOR PHOTO REQUIREMENTS:

• The impairment is required to be documented by preoperative photographs that must be available upon request. Photographs must include one view of the individual in primary position, one view looking up and one looking down and demonstrate the following:

• Photographs of the individual looking straight ahead must demonstrate:
  • The eyelid at or below the upper edge of the pupil; or
  • The margin reflex difference (distance from the upper lid margin to the reflected corneal light reflex at normal gaze) of 2 mm or less with the eyes in a straight gaze; or
  • Redundant eyelid tissue overhanging the upper eyelid margin and/or resting on the eyelashes; or
  • Photographs show the eyebrow below the supra-orbital rim; or
  • If both a blepharoplasty and ptosis repair are requested, two sets of photographs may be necessary to demonstrate the need for both procedures:
  • Photographs should show the excess skin above the eye resting on the eyelashes; and
  • Photographs should show persistence of lid lag, with the upper eyelid crossing or slightly above the pupil margin, despite lifting the excess skin above the eye off of the eyelids with tape.
  • If blepharoplasty, blepharoptosis repair, and brow ptosis repair are requested together, three sets of photographs may be necessary; and
  • The brow position is below the superior orbital rim;

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

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

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 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

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

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

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.

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.

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

Procedure Codes

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

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

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.

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

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

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

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

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

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

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

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

Port Wine Stain Treatmentmay 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

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

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

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

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 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:

• Chemical peel
• Correction of diastasis recti abdominis
• Excision, excessive skin, thigh, leg, hip, buttock, arm, forearm, or hand, submental fat pad, other area.
• Mastopexy
• Microdermabrasion
• Procedures/products/services via any treatment modality (e.g., laser, cryotherapy) performed solely for the treatment of post-acne scarring
• Salabrasion
• Suction assisted lipectomy done solely for cosmetic purposes
• Temporary hair removal (e.g., waxing, laser)

Procedure Codes

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

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

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

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)

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.