MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Cosmetic and Reconstructive Services

Number 10.01.514

Effective Date May 12, 2015

Revision Date(s) 05/12/15; 01/13/15; 10/13/14; 02/10/14; 01/14/13; 02/14/12

Replaces N/A

Policy

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Cosmetic Services

A procedure or drug may be considered cosmetic when the primary purpose is to preserve or improve appearance in the absence of a physical functional impairment. (See Policy Guidelines.)

Procedures that are usually considered cosmetic include but are not limited to the following:

  • Abdominoplasty (includes mini or modified abdominoplasty)
  • Arm lift (brachioplasty)
  • Body piercing
  • Breast augmentation
  • Breast lift (mastopexy)
  • Buttock or thigh lift
  • Dermabrasion
  • Diastasis recti repair
  • Electrolysis or laser hair removal
  • Excessive/redundant skin removal from limbs and other areas of the body
  • Fat grafts
  • Injectable dermal fillers used to sculpt body contours
  • Inverted nipple correction
  • Labia reduction (labiaplasty)
  • Lipectomy (includes belt lipectomy, circumferential lipectomy and others)
  • Lower body lift
  • Plastic repair of the ear
  • Rhytidectomy (face lift)
  • Tattoo (also see Reconstructive Services section)
  • Tattoo removal
  • Torosplasty
  • Treatment for skin wrinkles
  • Treatment for spider veins

Pharmaceutical Agents

Treatment with the following pharmaceutical agents is usually considered cosmetic (not an all-inclusive list):

  • Botox Cosmetic® or Juvéderm® (onabotulinum toxin for cosmetic use)
  • Egrifta® (tesamorelin)
  • Juvederm
  • Kybella™ (deoxycholic acid) injection
  • Latisse® (bimatoprost)
  • Mirvaso® (brimonidine topical gel)
  • Promiseb® (multiple ingredients)
  • Vaniqa® (eflornithine)
  • Any topical agent not containing an FDA-approved legend drug whose primary purpose is other than to preserve or improve appearance in the absence of a physical functional impairment.

Reconstructive Services

A procedure may be considered reconstructive when the primary purpose is to improve or restore function of a physical functional impairment of an abnormal body structure. (See Policy Guidelines and Definition of Terms.)

The following procedures may be considered medically necessary when criteria are met (see Related Policies):

  • Blepharoplasty
  • Breast reduction
  • Chemical peels
  • Collagen implant for urinary incontinence
  • Gynecomastia surgery
  • Panniculectomy
  • Scar revision when functional impairment symptoms are present
  • Skin tag removal when causing irritation and bleeding
  • Tattoo when done as part of breast reconstructive surgery after mastectomy

Collagen skin testing is considered medically necessary when the primary procedure meets medically necessary criteria, for example prior to collagen implantation for procedures to treat urinary incontinence or vesicoureteral reflux.

The Women’s Health and Cancer Rights Act of 1998

The Women’s Health and Cancer Rights Act of 1998 requires that in patients with breast cancer or a history of breast cancer, all stages of reconstruction of the breast on which a mastectomy was performed, surgery and reconstruction of the other breast to produce symmetrical appearance, prostheses and treatment of physical complications of the mastectomy including lymphedema are considered medically necessary.

A procedure is considered cosmetic when the medical necessity criteria in this policy are not met.

Related Policies

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2.01.519

Non-Pharmacologic Treatment of Rosacea

7.01.503

Reduction Mammoplasty for Breast-related Symptoms

7.01.508

Blepharoplasty, Blepharoptosis and Brow Ptosis Surgery

7.01.519

Treatment of Varicose Veins/Venous Insufficiency

7.01.521

Mastectomy for Gynecomastia

7.01.523

Panniculectomy and Excision of Redundant Skin

7.01.533

Reconstructive Breast Surgery/Management of Breast Implants

7.01.557

Gender Reassignment Surgery

7.01.558

Rhinoplasty and Septoplasty Surgery

9.02.500

Orthodontic Services for Treatment of Congenital Craniofacial Anomalies

9.02.501

Orthognathic Surgery

10.01.517

Noncovered Services and Procedures

Policy Guidelines

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Determination of Eligibility For Coverage

The final determination of eligibility for coverage should be based on application of the specific contract language based on the etiology of the defect and the presence or absence of documented physical functional impairment. (See Definition of Terms & Description sections)

Definition of Terms

When specific definitions are not present in a member’s plan, the following definitions will be applied:

Cosmetic: In this policy, cosmetic services are those which are primarily intended to preserve or improve appearance. Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient’s appearance or self-esteem.

Reconstructive Surgery: In this policy, reconstructive surgery refers to surgeries performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function.

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. The physical functional impairment can be due to structure, congenital deformity, pain, or other causes. Physical functional impairment excludes social, emotional and psychological impairments or potential impairments.

Description

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The coverage of medical and surgical therapies to treat musculoskeletal abnormalities and abnormalities of the integumentary system are often based on a determination of whether the abnormality is considered reconstructive or cosmetic in nature.

While reconstructive is often taken to mean that the service “returns the patient to whole” and cosmetic is often interpreted as meaning the restoration of appearance only, the application of these terms must be based on specific contract language that often varies from the above definitions.

Administering the contract language (also see Benefit Application)

The following general principles describe the issues to be determined in properly administering the contract language.

  1. The eligibility of a service for coverage may be based on either a specific benefit addressing cosmetic or reconstructive services or on its specific exemption or an exclusion for cosmetic or reconstructive services or both.
  2. Cosmetic services are usually considered to be those that are primarily to restore appearance and that otherwise do not meet the definition of reconstructive. The definition of reconstructive may be based on two distinct factors:
  • Whether the service is primarily indicated to improve or correct a functional impairment or is primarily to improve appearance; and
  • The etiology of the defect (e.g., congenital anomaly, anatomic variant, result of trauma, post-therapeutic intervention, disease process).
  1. The presence or absence of a functional impairment is a critical point in interpreting coverage eligibility. For musculoskeletal conditions, the concept of a functional impairment is straightforward. However, when considering dermatologic conditions, the function of the skin is more difficult to define. Procedures designed to enhance the appearance of the skin are typically considered cosmetic.

Injectable Dermal Fillers

The FDA has approved a number of injectable dermal fillers and volume-producing agents for treatment localized to the face in order to create a smoother appearance. These include, but are not limited to the following:

  • Calcium hydroxylapatite microsphere (Radiesse)
  • Hyaluronic acid (Restylane, Perlane, Juvederm Ultra, Elevess, Prevelle Silk, Teosyal, Revanesse Ultra)
  • Poly-L-lactic acid (Sculptra).

Cosmetic Genital Procedures

Vaginal procedures referred to as “rejuvenation” surgery are generally considered cosmetic as most are performed for aesthetic reasons to enhance appearance. Labia reduction surgery, also known as labiaplasty, removes excess skin or reshapes the labia, or vaginal lips. In the absence of genital mutilation, cancer, or traumatic injury a labiaplasty is cosmetic surgery. According to an ACOG committee opinion statement from 2007 (5) “these procedures are not medically indicated, and the safety and effectiveness of these procedures have not been documented.” (See Related Policies for procedures that are under gender reassignment surgery.)

Scope

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Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer services representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage.

Benefit Application

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Considerations when reviewing a case: Contract language may vary regarding the definition of reconstructive services for different categories of conditions. Two key questions must be asked.

  • it must be determined whether a functional impairment is present that would render its treatment medically necessary and thus eligible for coverage if no other exclusions apply.
  • if no functional impairment is present, the etiology of the condition must be determined and the contract language reviewed to see if this etiology is included in the definition of reconstructive services.

Rationale

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Policy reviewed by consensus without literature review.

References

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  1. American Society of Plastic Surgeons (ASPS). Cosmetic and reconstructive plastic surgery descriptions. 2015. Last accessed April, 2015.
  2. American Society of Plastic Surgeons (ASPS). 2013 Quick Facts. Cosmetic and reconstructive plastic surgery trends statistical report. 2013. Last accessed April, 2015.
  3. Women’s Health and Cancer Rights Act of 1998. http://www.dol.gov/ebsa/publications/whcra.html. Last accessed April, 2015.
  4. Carruthers, A. Injectable soft tissue fillers: Overview of clinical use. In: UpToDate, Ofori, AO (Ed), UpToDate, Waltham, MA, 2013.
  5. Committee on Gynecologic Practice, American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 378: Vaginal "rejuvenation" and cosmetic vaginal procedures. Obstet Gynecol. 2007 Sep;110(3):737-8. (Reaffirmed 2014). http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/Vaginal-Rejuvenation-and-Cosmetic-Vaginal-Procedures. Last accessed April, 2015.
  6. Liao LM, Creighton SM. Female genital cosmetic surgery: a new dilemma for GPs. Br J Gen Pract. 2011 Jan;61(582):7-8. PMID 21401983

Coding

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Codes

Number

Description

Medically Necessary Services

CPT

15780

Dermabrasion; total face (e.g., for acne scarring, fine wrinkling, rhytids, general keratosis)

 

15781

Dermabrasion; segmental, face

 

15782

Dermabrasion; regional, other than face

 

15783

Dermabrasion; superficial, any site, (e.g., tattoo removal)

 

15788

Chemical peel, facial; epidermal

 

15789

Chemical peel, facial; dermal

 

15792

Chemical peel, nonfacial; epidermal

 

15793

Chemical peel, nonfacial; dermal

 

15830

Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy

 

17106

Destruction of cutaneous vascular proliferative lesions (e.g. laser technique; less than 10 sq cm

 

17107

Destruction of cutaneous vascular proliferative lesions (e.g. laser technique; 10.0 to 50.0 sq cm

 

17108

Destruction of cutaneous vascular proliferative lesions (e.g. laser technique); over 50.0 sq cm

 

21120

Genioplasty; augmentation (autograft, allograft, prosthetic material)

 

21121

Genioplasty; sliding osteotomy, single piece

 

21122

Genioplasty; sliding osteotomies, 2 or more osteotomies (e.g. wedge excision or bone wedge reversal for asymmetrical chin)

 

21123

Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)

 

21125

Augmentation, mandibular body or angle; prosthetic material

 

21127

Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft)

 

21137

Reduction forehead; contouring only

 

21138

Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft)

 

21139

Reduction forehead; contouring and setback of anterior frontal sinus wall

 

21141

Reconstruction midface, LeFort I; single piece, segment movement in any direction (e.g. for Long Face Syndrome), without bone graft

 

21142

Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft

 

21143

Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft

 

21145

Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts)

 

21146

Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g. ungrafted unilateral alveolar cleft)

 

21147

Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g. ungrafted bilateral alveolar cleft or multiple osteotomies)

 

21150

Reconstruction midface, LeFort II; anterior intrusion (e.g. Treacher-Collins Syndrome)

 

21151

Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts)

 

21154

Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I

 

21155

Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I

 

21159

Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (e.g. mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I

 

21160

Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (e.g. mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I

 

21193

Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft

 

21194

Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft)

 

21195

Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation

 

21196

Reconstruction of mandiblar rami and/or body, sagittal split; with internal rigid fixation

 

21198

Osteotomy, mandible, segmental

 

21206

Osteotomy, maxilla, segmental (e.g. Wassmund or Schuchard)

 

21208

Osteoplasty, facial bones; segmentation (autograft, allograft or prosthetic implant)

 

21209

Osteoplasty, facial bones; reduction

 

21270

Malar augmentation, prosthetic material

 

21280

Medial canthopexy (separate procedure)

 

21282

Lateral canthopexy

 

21295

Reduction of masseter muscle and bone (e.g. for treatment of benign masseteric hypertrophy); extraoral approach

 

21296

Reduction of masseter muscle and bone (e.g. for treatment of benign masseteric hypertrophy); intraoral approach

 

28344

Reconstruction, toe(s); polydactyly

 

36470

Injection of sclerosing solution; single vein

 

36471

Injection of sclerosing solution; multiple veins, same leg

 

65760

Keratomileusis

 

65765

Keratophakia

 

65767

Epikeratoplasty

 

67900

Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)

 

67901

Repair of blepharoptosis; frontalis muscle technique with suture or other material (e.g. banked fascia)

 

67902

Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia)

 

67903

Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach

 

67904

Repair of blepharoptosis; (tarso) levator resection or advancement, external approach

 

67906

Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia)

 

67908

Repair of blepharoptosis; conjectivo-tarso-Muller’s muscle-levator resection (e.g., Fasanella-Servat type)

 

67911

Correction of lid retraction

 

67912

Correction of lagophthalmos, with implantation of upper eyelid lid load (e.g., gold weight)

 

67950

Canthoplasty (reconstruction of canthus)

 

67961

Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid margin

 

67966

Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; over one-fourth of lid margin

HCPCS

L8600

Implantable breast prosthesis, silicone or equal

Cosmetic Services

CPT

11920

Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less

 

11921

Tattooing, intradermal introduction of insoluable opaque pigments to correct color defects of skin, including micropigmentation; 6.1 sq cm to 20.0 sq cm

 

11922

Tattooing, intradermal introduction of insoluable opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure)

 

11950

Subcutaneous injection of filling material (e.g. collagen); 1cc or less\

 

11951

Subcutaneous injection of filling material (e.g. collagen); 1.1 to 5.0 cc

 

11952

Subcutaneous injection of filling material (e.g. collagen); 5.1 to 10.0 cc

 

11954

Subcutaneous injection of filling material (e.g. collagen); over 10.0 cc

 

11960

Insertion of tissue expander(s) for other than breast, including subsequent expansion

 

11970

Replacement of tissue expander with permanent prosthesis

 

11971

Removal of tissue expander(s) without insertion of prosthesis

 

15786

Abrasion; single lesion (e.g. keratosis, scar)

 

15787

Abrasion; each additional four lesions or less (List separately in addition to code for primary procedure)

 

15819

Cervicoplasty

 

15824

Rhytidectomy; forehead

 

15825

Rhytidectomy; neck with platysmal tightening (platsymal flap, P-flap)

 

15826

Rhytidectomy; glabellar frown lines

 

15828

Rhytidectomy; cheek, chin, and neck

 

15829

Rhytidectomy; superficial musculoapneurotic system SMAS flap

 

15832

Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh

 

15833

Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg

 

15834

Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip

 

15835

Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock

 

15836

Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm

 

15837

Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand

 

15838

Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad

 

15839

Excision excessive skin and subcutaneous tissue (includes lipectomy); other areas

 

15847

Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g. abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)

 

15876

Suction assisted lipectomy; head and neck

 

15877

Suction assisted lipectomy; trunk

 

15878

Suction assisted lipectomy; upper extremity

 

15879

Suction assisted lipectomy; lower extremity

 

19316

Mastopexy

 

19324

Mammoplasty, augmentation; without prosthetic implant

 

19325

Mammoplasty, augmentation; with prosthetic implant

 

19340

Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction

 

19342

Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction

 

19350

Nipple/areola reconstruction

 

19355

Correction of inverted nipples

 

19380

Revision of reconstructed breast

 

21230

Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)

 

21235

Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)

 

30120

Excision or surgical planning of skin or nose for rhinophyma

 

36468

Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk

 

36469

Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); face

 

40500

Vermilionectomy (lip shave), with mucosal advancement

 

56620

Vulvectomy simple; partial

 

69300

Otoplasty, protruding ear, with or without size reduction

HCPCS

Q2026

Injection, Radiesse, 0.1 ml

 

Q2028

Injection, sculptra, 0.5 mg

Non-covered Services

CPT

69090

Ear piercing

Not Reviewed

CPT

17380

Electrolysis epilation, each 30 minutes

 

69320

Reconstruction external auditory canal for congenital atresia, single stage

HCPCS

Q3031

Collagen skin test

Appendix

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N/A

History

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Date

Reason

09/13/11

New Policy – Add to Administrative section.

02/14/12

Replace Policy – Policy updated with an additional policy statement indicating collagen skin testing as medically necessary when the primary procedure meets medically necessary criteria. HCPCS code Q3031 was added to the policy.

04/16/12

Related Policies updated: 7.01.09 removed, as this policy has been archived.

07/20/12

Related Polices updated: the title of 2.01.47 changed as of July 10, 2012.

01/29/13

Replace policy. No changes.

06/03/13

Coding update. CPT code 15777 added to the policy.

06/04/13

Update Related Policies. Change title to 7.01.508.

09/30/13

Update Related Policies. Add 9.02.500.

02/24/14

Replace policy. HCPCS code Q2026 and Q2028; are considered cosmetic. Policy statement clarified – Injectable replaced with injectable dermal fillers. Added reference 3. CPT codes 15775 – 15776 are on the non-covered list and have been removed from the policy; 15777 is an add-on code and has also been removed; 15820-15823, 19300 and 19318 have been removed as they apply to and are included in specific policies.

04/18/14

Update Related Policies. Add 9.02.501.

10/13/14

Interim update. Adding blanket statement indicating that when coverage criteria are not met, services are considered cosmetic. Update coding table to delineate non-covered, cosmetic and medically necessary services.

12/01/14

Update Related Policies. Change title 7.01.508.

12/17/14

Coding update. CPT codes 21230 and 21235 added to the policy.

01/13/15

Minor update. Removed Rhinoplasty and Septoplasty from policy statement and CPT codes 30400-30465;these are surgeries addressed in policy 7.01.558. Added 7.01.558 to Related Policies section; 2.01.514 removed from same section; it has been archived. Pharmacy update: cosmetic indications added for pharmaceutical agents which are considered cosmetic.

03/13/15

Coding update. CPT code 69300 adding to the list of codes considered cosmetic.

05/12/15

Annual Review. Policy reviewed. The following procedures added to the policy cosmetic procedures list: abdominioplasty (includes mini or modified abdominioplasty), brachioplasty, diastasis recti surgery, labiaplasty, lipectomy (includes belt & circumferential lipectomy), lower body lift, tattoo removal, thigh lift, torosoplasty. Kybella added to the list of cosmetic pharmaceuticals. Policy 7.01.523 Title updated in Related Policies section. Definition of Terms moved to Policy Guidelines from the Benefit Application section. Cosmetic genital procedures added to Description section. Reference 1 updated from 2010 ASPS Statistics report to the 2013 Plastic Surgery Statistics Report. References 1, 5, 6 added. CPT 15847 moved from Medically Necessary to Cosmetic codes list. CPT 56620 added to cosmetic codes list. Policy statement changed as noted.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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