Highmark Medicare Advantage Medical Policy in West Virginia

Section:	CMS National Guidelines
Number:	N-145
Topic:	Cosmetic Surgery vs. Reconstructive Surgery - NCD 140.4
Effective Date:	January 26, 2009
Issued Date:	January 26, 2009

General Policy

For services on or after 06/18/2011, see policy S-28

Cosmetic surgery includes any surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning malformed body member. For example, this exclusion does not apply to surgery in connection with treatment of severe burns or repair of the face following a serious automobile accident, or to surgery for therapeutic purposes which coincidentally also serves some cosmetic purpose.

Reconstructive surgery is performed to improve or restore bodily function and is generally eligible for payment.

Indications and Limitations of Coverage

Cosmetic surgery or expenses incurred in connection with such surgery are not covered. A provider can bill the member for the denied service.

However, medical and hospital services are covered if the services are “not related to” noncovered services.

Plastic Surgery to Correct Moon Face (140.4)

Surgery to correct a condition of “moon face” which developed as a side effect of cortisone therapy does not meet the exception to the rule of exclusion and therefore, is considered cosmetic and not covered.

See Medical Policy Bulletin S-134 for guidelines on Blepharoplasty/Blepharoptosis.

See Medical Policy Bulletin N-143 for guidelines on the Breast Reconstruction Following Mastectomy.

See Medical Policy Bulletin S-196 for guidelines on the Removal of Benign or Premalignant Skin Lesions.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

On-Line Manual 100-03, Chapter 1, Section 140.4

On-Line Manual 100-02, Chapter 16, Section 120

On-Line Manual 100-02, Chapter 16, Section 180

www.cms.gov

www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

ICD-9 Diagnosis Codes

ICD-10 Diagnosis Codes

Glossary

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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.