BlueCross and BlueShield of Montana Medical Policy/Codes
Cosmetic and Reconstructive Procedures
Chapter: Surgery: Procedures
Current Effective Date: December 27, 2013
Original Effective Date: December 27, 2013
Publish Date: September 27, 2013
Revised Dates: September 6, 2013
Description

The coverage of medical and surgical procedures to treat abnormalities of the musculoskeletal and of the integumentary systems (i.e., the skin, subcutaneous and accessory structures including the breast) is often based on a determination of whether the abnormality is considered cosmetic or reconstructive in nature.

COSMETIC PROCEDURES are intended solely to improve appearance and self-esteem not to restore bodily function, or correct deformity.

RECONSTRUCTIVE SURGERY restores form but does not always correct or restore bodily function. It is generally done to improve function but may also be done to approximate a normal appearance.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

NOTE: Determinations of whether a proposed therapy would be considered reconstructive or cosmetic should always be interpreted in the context of the specific contract benefits language. In general, the presence of a functional impairment would render its treatment medically necessary and thus not subject to contractual definitions of reconstructive or cosmetic.

COSMETIC PROCEDURES:

Services that are provided primarily to alter and/or enhance appearance in the absence of documented impairment of physical function are considered to be cosmetic.

The majority of contracts have exclusions for cosmetic services or supplies. The following table below indicates services that may be considered either cosmetic or reconstructive, depending on the diagnosis, and documentation of progressive functional impairment. This list is not intended to be all inclusive. Refer to the individual medical policy if indicated for a specific procedure.

Cosmetic procedures would not be eligible for benefits because of psychiatric, psychosocial or emotional issues.

RECONSTRUCTIVE PROCEDURES:

Procedures are considered reconstructive and therefore may be considered medically necessary when:

  • There is documented evidence of physical functional impairment; OR
  • Services are provided primarily to correct documented progressive impairment of physical function that interferes with the performance of activities of daily living; OR
  • The conditions of impairment must meet the definition of reconstructive services in the benefit contract of the member for whom a procedure is being considered.

Documentation for reconstructive surgery must include, appropriate historical medical record documentation and may include any of the following:

  • Photographs; and/or
  • Consultation reports; and/or
  • Operative reports and/or other applicable hospital records (examples: pathology report, history and physical); and/or
  • Office records; and/or
  • Letters with pertinent information from:
  1. Providers;
  2. Subscribers.

The plan requires medical records for determination of medical necessity. When medical records are requested, a letter of support and/or explanation may be helpful, but alone will not be considered sufficient documentation to make a medical necessity determination.

NOTE:  The following table contains a listing of cosmetic and reconstructive procedures, which include but are not limited to the following:

Clinical Conditions

Reconstructive

Cosmetic

Abdominoplasty

When the following conditions are met:

  • Panniculus hangs to or below the level of the pubis; and causes chronic intertrigo that consistently reoccurs or remains refractory to appropriate medical therapy that includes systemic antibiotics, topical anti-infectives, anti-inflammatory medication and appropriate skin hygiene; OR
  • Repair of diastasis recti in the presence of a true midline hernia (ventral or umbilical). 

When the procedure is performed to:

  • Remove excess skin and fat from the middle and lower abdomen in order to contour and alter the appearance of the abdominal area to  improve appearance
  • Repair diastasis recti without the presence of a true midline hernia.

 

 

Breast augmentation with implant.

See Medical Policy "Breast Implant, Removal and/or Insertion"

See Medical Policy "Breast Implant, Removal and/or Insertion"

Blepharoplasty.

See Medical Policy "Blepharoplasty, Blepharoptosis, Brow Ptosis Repair"

See Medical Policy "Blepharoplasty, Blepharoptosis, Brow Ptosis Repair"

Chemical Peels.

See Medical policy "Chemical Peels"

See Medical Policy "Chemical Peels"

Congenital Anomaly.

Correction of a condition existing at birth, which is a significant deviation from common anatomical form.

Over the age of 19.

Gynecomastia.

See Medical Policy "Mastectomy for Gynecomastia"

See Medical policy "Mastectomy for Gynecomastia"

Hair Transplant (Hairplasty).

For permanent alopecia as a result of trauma.

For male pattern alopecia,

For alopecia due to disease or therapeutic procedures.

Injectable Implant

Radiesse Laryngeal Implant for indications of vocal fold medialization and vocal fold insufficiency in accordance with FDA labeling.

Radiesse® for all indications including but not limited to: subdermal implantation for restoration and/or correction of the signs of facial fat loss (lipodystrophy) in people with human immunodeficiency virus, and subdermal implantation for the correction of moderate to severe facial wrinkles and folds, such as nasolabial folds.

Keloid removal.

When the following conditions exist:

  • Ulceration or infection with or without sinus tracts;
  • Extremely large, painful keloid associated with stretching;
  • Rapid growth of the keloid interferes with normal function.

Removal of small keloid which does not interfere with normal function.

Mammaplasty & contralateral breast surgery.

See Medical Policy "Reconstructive and Contralateral Mammaplasty"

See Medical Policy "Reconstructive and Contralateral Mammaplasty"

Mammaplasty, reduction.

See Medical Policy "Reduction Mammaplasty"

See Medical Policy "Reduction Mammaplasty"

Mandibular or maxillary resection.

See Medical Policy "Mastopexy"

See Medical Policy "Mastopexy"

Mastectomy.

See Medical Policy "Breast Surgery for Prophylaxis or Cancer Prevention"

See Medical Policy "Breast Surgery for Prophylaxis or Cancer Prevention"

Mastectomy Simple or Prophylactic.

See Medical Policy "Breast Surgery for Prophylaxis or Cancer Prevention"

See Medical Policy "Breast Surgery for Prophylaxis or Cancer Prevention"

Mastectomy Subcutaneous.

See Medical Plicy "Breast Surgery for Prophylaxis or Cancer Prevention"

See Medical Plicy "Breast Surgery for Prophylaxis or Cancer Prevention"

Mastopexy.

See Medical Policy "Mastopexy"

See Medical Policy "Mastopexy"

Mentoplasty, Genioplasty or chin implant.

Cosmetic for all indications.

Cosmetic for all indications.

Obesity.

See Medical Policy "Bariatric Surgery"

See Medical Policy "Bariatric Surgery"

Otoplasty.

  • Ears are absent; or
  • Deformed from trauma, surgery, disease or congenital defects.

To correct large or protruding ears.

Pectus excavatum or pectus carinatum.

  • Documentation of complications from sternal deformities including but not limited to:
  • Cardiopulmonary impairment documented by respiration and/or cardiac function test;
  • Frequent lower respiratory tract infections;
  • Asthma; or 
  • Exercise limitations;
  • Atypical chest pain;
  • Pectus index > 3.25.

Primarily to alter appearance over the age of 19.

Photodynamic Therapy (PDT).

See Medical Policy "Photodynamic Therapy (PDT) for the Treatment of Actinic Keratoses (AK) and Other Skin Lesions"

Skin rejuvenation.

Hair removal or other cosmetic indications.

Rhytec Portrait® Skin Regeneration

Cosmetic for all indications.

Cosmetic for all indications.

Port Wine Stain.

See Medical Policy "Laser Treatment of Congenital Port Wine Stain (PWS), Hemangiomas, and Other External Vascular Malformations"

See Medical Policy "Laser Treatment of Congenital Port Wine Stain (PWS), Hemangiomas, and Other External Vascular Malformations"

Psoriasis.

See Medical Policy "Phototherapy for Dermatologic Conditions"

See Medical Policy "Phototherapy for Dermatologic Conditions"

Refractive keratoplasty.

See Medical Policy "Refractive and Therapeutic Keratoplasty"

See Medical Policy "Refractive and Therapeutic Keratoplasty"

Restoration of body form.

  • Following an accidental injury or trauma; 
  • Disfiguring or extensive scars resulting from neoplastic surgery;
  • As a general rule restoration should be performed within two years of the accident or initial injury;
  • Following a medically necessary mastectomy regardless of when the mastectomy was performed;
  • Correction of inverted nipples only if a functional impairment is present;
  • Collagen implantation to restore the natural contour to skin that has been damaged by trauma or congenital abnormalities;
  • Cystocele and/or urethrocele repair;
  • Testicular prostheses after medically necessary orchiectomy for indications including, but not limited to torsion and undescended testicle;
  • Testicular prosthesis in the case of ambiguous genitalia.
  • Body piercing;
  • Glabellar frown line;
  • Testicular prosthesis;
  • Buttock or thigh lift;
  • Neck tuck;
  • Hirsutism;
  • Skin tags;
  • Papillomas;
  • Correction of inverted nipples without functional impairment;
  • Collagen implant as surgery for acne;
  • Surgery for acne scarring;
  • Restore the natural contour of skin damaged by age;
  • Surgical reshaping of the nose for Rhinophyma;
  • Relume™ for treatment of Stretch Marks;
  • Sculptra™ (injectable Poly-L-Lactic Acid) for all indications;
  • EGRIFTA™ (tesamorelin) for all indications including but not limited to: the reduction of excess abdominal fat in HIV-infected patients with lipodystrophy.

Rhinoplasty

See Medical Policy "Nasal and Sinus Surgery"

See Medical Policy "Nasal and Sinus Surgery"

Rhytidectomy

For treatment of burns.

For treatment of the face for aging skin.

Sclerotherapy

See Medical Policy "Varicose Vein Management"

See Medical Policy "Varicose Vein Management"

Septoplasty

See Medical Policy "Nasal and Sinus Surgery"

See Medical Policy "Nasal and Sinus Surgery"

Suction Assisted Lipectomy or body contouring with silicone or liposuction.

Body contouring following surgery, is an integral part of the procedure.

Suction assisted lipectomy, by any method. 

Scar revision

Resulting from trauma or   surgery. Documentation must show conservative treatment of the scar has failed.

When performed to improve appearance and not associated with an injury or the result of neoplastic surgery.

Strabismus

Regardless of:

  • The age of the patient;
  • Date of the origin of deviation;
  • Subsequent surgical corrections.

None

Tattoos

  • Excision/treatment of traumatic or therapeutic tattoos;
  • For nipple/areola reconstruction following mastectomy.

To correct color defects of the skin.

NOTE:

  • Check contract for specific benefit coverage and definitions. 
  • For coverage of specific procedures please see the specific medical policy where indicated.

Special Comment regarding Cosmetic Services:  Determination of benefit coverage for procedures considered to be cosmetic is based on how a member’s contract defines cosmetic services and their eligibility for benefit coverage.

Policy Guidelines

There is not a specific CPT or HCPCS code for Rhytec Portrait® Skin Regeneration. Some providers may bill this procedure using CPT code 17111.  

Rationale

Determinations of whether a proposed therapy would be considered reconstructive or cosmetic should always be interpreted in the context of the specific benefit language.

The requirement of the presence of a functional impairment for a specific etiology may vary as applied to dermatologic conditions. See the related documents list for individual policies which supersede generic language describing cosmetic and reconstructive procedures. It should be noted that the presence of a functional impairment would render treatment medically necessary and thus not subject to contractual definitions of reconstructive or cosmetic.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes
Refer to the ICD-9-CM Manual.
ICD-10 Codes

Refer to ICD-10-CM Manual.

Procedural Codes: 11200, 11201, 11920, 11921, 11922, 11950, 11951, 11952, 11954, 11960, 11970, 15220, 15775, 15776, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15824, 15825, 15826, 15828, 15829, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879, 17340, 17380, 19355, 21120, 21121, 21122, 21123, 21740, 21742, 21743, 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 54660, 69090, 69300, 69310, 69320, 96567, G0429, J3490, Q2026, Q2027
References
  1. AAD-Position Statement on The Definitions of Cosmetic and Reconstructive Surgery. 1995 American Academy of Dermatology Association. H-475.992 Definitions of “Cosmetic” and “Reconstructive” Surgery.” http://www.addassociation.org .
  2. G.D. Monheit and M.A.Chastain. Chemical Peels.  Facial Plastic Surgical Clinics of North America (2001 May) 9(2):239-55.
  3. Botulinum Toxin. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2002 April) 5.01.05.
  4. Sclerotherapy as a Treatment of Varicose Veins. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2003 February) 7.01.55.
  5. Reconstructive/Cosmetic Services (Archived). Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2003 Mar) Administrative 10.01.09.
  6. Chemical Peels. Chicago, Illinois:  Blue Cross Blue Shield Association Medical Policy Reference Manual. (2003 Mar) 8.01.16.
  7. J.E. Fulton and S.Porumb. Chemical peels: their place within the range of resurfacing techniques. American Journal of Clinical Dermatology (2004) 5(3):179-87.
  8. State of Texas. Texas Insurance Code. Texas Administrative Code.  Benefits for reconstructive surgery incident to a mastectomy. Article 21.531, Section 11.508(a) (5) (A) Subchapter F, Title 28.
  9. State of Texas. Reconstructive surgery for craniofacial abnormalities in a child. Texas Insurance Code.
  10. Article 21.53W, State of Illinois. Breast Implant Removal. Illinois Mandated Benefits, offers, And Coverage’s for Accident & Health Insurance and HMOs.  215ILCS5/370r, 215 ILCS 125/4-6.3.
  11. State of New Mexico. Breast Reconstruction & Prosthetic Devices. New Mexico Mandates for Health Insurance Plans. MHCP Rule, 13 NMAC 10.13.9.7.2. (1997, 1998).         
  12. Department of Health & Human Services. Drug Approval Letter. 08/03/2004.  Sculptra (injectable poly-L-lactic acid) approved for restoration and/or correction of the signs of facial fat loss (lipoatrophy) in people with human immunodeficiency virus. http://www.accessdata.fda.gov . (accessed 10/1/2010).
  13. Department of Health & Human Services.  Drug Approval Letter. 12/22/2006. Radiesse approved for subdermal implantation for restoration and/or correction of the signs of facial fat loss (lipoatrophy) in people with human immunodeficiency virus. http://www.accessdata.fda.gov .(accessed 10/1/2010).
  14. Department of Health & Human Services.  Drug Approval Letter. 12/22/2006.  Radiesse approved for subdermal implantation for the correction of moderate to severe facial wrinkles and folds, such as nasolabial folds. http://www.accessdata. fda.gov . (accessed 10/1/2010).
  15. Specialty Pharmacy Combined Capacity (SPCC) Report #1-2011 Tesamorelin (EGRIFTA®).  Chicago, Illinois: Blue Cross Blue Shield Association – Technology Evaluation Center Assessment (TEC) (2011 January) 1-47.
  16. Department of Health & Human Services. Drug Approval Letter. 11/10/2010. Egrifta (tesamorelin for injection) for the reduction of excess abdominal fat in HIV-infected patients with lipodystrophy. http://www.accessdata.fda.gov (accessed 5/2/2011).
  17. Department of Health and Human Services. Center for Devices and Radiological Health. Section 510(k) premarket notification. K070090 Radiesse Laryngeal Implant. www.accessdata.fda.gov (accessed 6/11/2013).
History
September 2013 New 2013 BCBSMT medical policy.
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Cosmetic and Reconstructive Procedures