For services prior to 06/18/2011, see policy N-145.

Reconstructive Surgery
Reconstructive surgery is 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 but may also be done to approximate a normal appearance.

Cosmetic Surgery
Cosmetic surgery is performed to reshape normal structures of the body to improve the patient's appearance and self-esteem.

Benefits are provided for complications arising from cosmetic surgery as long as infection, hemorrhage or other serious documented medical complication occurs and the member has been officially discharged from the facility.

Payment will be made for the following procedures when performed for the reasons indicated:

Dermabrasion
Coverage will be provided when correcting defects resulting from traumatic injury, surgery or disease.

Abdominal Lipectomy/Panniculectomy
Abdominal lipectomy/panniculectomy is surgical removal of excessive fat and skin from the abdomen. When surgery is performed to alleviate such complicating factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis, such surgery is considered reconstructive. Preoperative photographs may be required to support justification and should be supplied upon request.

Panniculectomy is considered medically necessary when the panniculus hangs below the level of the pubis, and the medical records document that the panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs over three months while receiving appropriate medical therapy, or remains refractory to appropriate medical therapy over a period of three months.

NOTE:

If the procedure is being performed following significant weight loss, in addition to meeting the criteria noted above, there should be evidence that the individual has maintained a stable weight for at least three to six months. If the weight loss is the result of bariatric surgery, abdominoplasty/panniculectomy should generally not be performed until at least 18 months after bariatric surgery and only when weight has been stable for at least the most recent three to six months.

Reconstructive Breast Surgery: Removal of Breast Implants
For a patient who has had an implant(s) placed for reconstructive or cosmetic purposes, treatment of any one or more of the following conditions is considered to be medically necessary:

• Broken or failed implant.
• Infection.
• Implant extrusion.
• Siliconoma or granuloma.
• Interference with diagnosis of breast cancer.
• Painful capsular contracture with disfigurement.

Reduction Mammoplasty
Macromastia (breast hypertrophy) is disproportionate volume and weight of breast tissue relative to the general body habitus. Breast hypertrophy may adversely affect other body systems (e.g., musculoskeletal, respiratory, integumentary). Unilateral hypertrophy may result in symptoms following contralateral mastectomy.

Reduction mammoplasty is performed:

• To reduce the size of the breasts and help ameliorate symptoms caused by hypertrophy.
• To reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery.

The medical necessity for reduction mammoplasty is limited to circumstances in which:

• There are signs and/or symptoms resulting from the enlarged breasts (macromastia) that have not responded adequately to non-surgical interventions.
• To improve symmetry following cancer surgery on one breast.

Non-surgical interventions preceding reduction mammoplasty should include as appropriate, but are not limited to, the following:

• Determining the macromastia is not due to an active endocrine or metabolic process.
• Determining the symptoms are refractory to appropriately fitted supporting garments, or following unilateral mastectomy, persistent with an appropriately fitted prosthesis or reconstruction therapy at the site of the absent breast.
• Determining that dermatologic signs and/or symptoms are refractory to, or recurrent following, a completed course of medical management.

A reasonable and necessary reduction mammoplasty could be indicated in the presence of significantly enlarged breasts and the presence of at least one of the following signs and/or symptoms:

• Back pain from macromastia, unrelieved by:
  • Conservative analgesia.
  • Supportive measures (garment, etc.).
  • Physical therapy.
• Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity.
• Intertriginous maceration or infection of the inframammary skin refractory to dermatologic measures.
• Shoulder grooving with skin irritation by supporting garment (bra strap).

Considerable attention has been given to the amount of breast tissue removed in differentiating between cosmetic and medically necessary reduction mammoplasty. Arbitrary minimum weight breast tissue removed criteria do not consistently reflect the consequences of mammary hypertrophy in individuals with a unique body habitus. There are wide variations in the range of height, weight and associated breast size that cause symptoms. The amount of tissue that must be removed to relieve symptoms will vary and depend upon these variations. The following are guidelines (not rules) that address the patient’s weight and the amount of breast tissue removed:

Table I

• 95-119 lbs. 300 grams excised per breast.
• 110-130 lbs. 400 grams excised per breast.
• 130+ lbs. 500 grams excised per breast.

Coverage of reduction mammoplasty is limited to those circumstances where the medical record supports the following:

• The signs and/or symptoms have been present for at least six months.
• Medical treatment and/or physical interventions have not adequately alleviated symptoms.

Rhinoplasty
Nasal surgery is defined as any procedure performed on the external or internal structures of the nose, septum or turbinate. This surgery may be performed to improve abnormal function, reconstruct congenital or acquired deformities, or to enhance appearance. It generally involves rearrangement or excision of the supporting bony and cartilaginous structures and incision or excision of the overlying skin of the nose.

Nasal surgery, including rhinoplasty, may be reconstructive or cosmetic in nature. Current CPT codes do not allow distinction of cosmetic or reconstructive procedures by specific codes; therefore, categorization of each procedure is to be distinguished by the presence or absence of specific signs and/or symptoms.

Reconstructive Nasal Surgery
When nasal surgery, including rhinoplasty, is performed to improve nasal respiratory function, correct anatomic abnormalities caused by birth defects or disease, or revise structural deformities produced by trauma, the procedure should be considered reconstructive.

Rhinoplasty is medically necessary when there is photographic documentation ( all of the following: frontal, lateral and worm’s eye view) of the individual’s condition, and the procedure is performed for correction or repair of any of the following:

• Nasal deformity secondary to a cleft lip/palate or other congenital craniofacial deformity causing a functional impairment.
  
  
• Chronic, nonseptal, nasal obstruction due to vestibular stenosis (i.e., collapsed internal valves).
  
  
• Secondary to trauma, disease, congenital defect with nasal airway obstruction unresponsive to a recent trial of conservative medical management lasting at least six weeks that has either not resolved after previous septoplasty/turbinectomy or would not be expected to resolve with septoplasty/turbinectomy alone.

Septoplasty is medically necessary when performed for any of the following indications:

• Septal deviation causing nasal airway obstruction that has proved unresponsive to a recent trial of conservative medical management lasting at least six weeks.
  
  
• Recurrent sinusitis secondary to a deviated septum that does not resolve after appropriate medical and antibiotic therapy.
  
  
• Recurrent epistaxis related to a septal deformity.
  
  
• Asymptomatic septal deformity that prevents access to other transnasal areas when such access is required to perform medically necessary procedures (e.g., ethmoidectomy).
  
  
• Performed in association with cleft lip or cleft palate repair.
  
  
• Obstructed nasal breathing due to septal deformity or deviation that has proved unresponsive to medical management and is interfering with the effective use of medically necessary Continuous Positive Airway Pressure (CPAP) for the treatment of an obstructive sleep disorder.

Reconstructive nasal surgery is generally directed to improve nasal respiratory function (e.g., airway obstruction or stricture, synechia formation); repair defects caused by trauma (e.g., nasoseptal deviation, intranasal cicatrix, dislocated nasal bone fractures, turbinate hypertrophy); treat congenital anatomic abnormalities (e.g., cleft lip nasal deformities, choanal atresia, oronasal or oromaxillary fistula); treat nasal cutaneous disease (e.g., rhinophyma, dermoid cyst); or to replace nasal tissue lost after tumor ablative surgery.

Dermal Injections
Facial Lipodystrophy syndrome (FLS) is often characterized by a loss of fat that results in a facial abnormality such as severely sunken cheeks.  The patient’s physical appearance may contribute to psychological conditions (e.g., depression) or adversely impact a patient’s adherence to antiretroviral regimens (therefore jeopardizing their health) and both of these are important health-related outcomes of interest in this population.  Therefore, improving a patient’s physical appearance through the use of dermal injections could improve these health-related outcomes.

Dermal injections for FLS are only reasonable and necessary using dermal fillers approved by the Food and Drug Administration (FDA) for this purpose and then only in HIV-infected members when FLS caused by antiretroviral HIV treatment is a significant contributor to their depression.

LCD Individual Consideration
Corrective facial surgery will be considered cosmetic rather than reconstructive when there is no functional impairment present.  However, some congenital, acquired, traumatic or developmental anomalies may not result in functional impairment, but are so severely disfiguring as to merit consideration for corrective surgery.

For example, the craniofacial anomalies associated with Treacher Collins’ syndrome should be reviewed on an individual consideration basis.

Reasons for Noncoverage

Cosmetic surgery performed purely for the purpose of enhancing one's appearance is not eligible for coverage. A provider can bill the member for the non-covered procedure.

Corrective facial surgery will be considered cosmetic rather than reconstructive when there is no functional impairment present. A provider can bill the member for the non-covered procedure. However, some congenital, acquired, traumatic or developmental anomalies may not result in functional impairment, but are so severely disfiguring as to merit consideration for corrective surgery.

If a non-covered cosmetic surgery is performed in the same operative period as a covered surgical procedure, benefits will be provided for the covered surgical procedure only.

However, surgery to correct congenital defects, developmental abnormalities, trauma, infections, tumors or disease may be covered because the surgery is considered reconstructive in nature.

Cosmetic surgery performed to treat psychiatric or emotional problems is generally not covered. A provider can bill the member for the non-covered procedure.

Dermabrasion performed for post-acne scarring is classified as cosmetic and is not covered for payment. A provider can bill the member for the non-covered procedure.

Cosmetic surgery to reshape the breasts to improve appearance is not a benefit. Cosmetic signs and/or symptoms would include ptosis, poorly fitting clothing and member perception of unacceptable appearance. A provider can bill the member for the non-covered procedure.

Panniculectomy is considered experimental and investigational for minimizing the risk of hernia formation or recurrence. There is no adequate evidence that pannus contributes to hernia formation. The primary cause of hernia formation is an abdominal wall defect or weakness, not a pulling effect from a large or redundant pannus. A provider can bill the member for the non-covered procedure.

Abdominoplasty or panniculectomy is considered not covered when performed primarily for any of the following indications because it is considered not medically necessary (this list may not be all-inclusive).  A provider cannot bill the member for the non-covered procedure.

• Treatment of neck or back pain.
• Improving appearance (i.e., cosmesis).
• Repairing abdominal wall laxity or diastasis recti.
• Treating psychological symptomatology or psychosocial complaints.
• When performed in conjunction with abdominal or gynecological procedures (e.g., abdominal hernia repair, hysterectomy, obesity surgery) unless criteria for panniculectomy and abdominoplasty are met separately.

Rhinoplasty is not covered when performed for either of the following indications because it is considered cosmetic in nature or not medically necessary. A provider can bill the member for the non-covered procedure.

• Solely for the purpose of changing appearance.
• As a primary treatment for an obstructive sleep disorder when the above criteria for approval have not been met.

When nasal surgery is performed solely to improve the patient's appearance in the absence of any signs and/or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and non-covered.  The provider can bill the member for the non-covered procedure.

Services billed with a diagnosis code that is not listed in the Diagnosis Codes section of this policy or meeting criteria on the medical policy, will be denied as not medically necessary. Exceptions will be considered on a case-by-case basis. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Compliance with the provisions in this policy is subject to monitoring by post-payment data analysis and subsequent medical review.

Documentation Requirements

Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available upon request.

For mammoplasty:

• The member's medical record must contain, and be available for review on request, the following information:
  
  
  • Height and weight.
    
    
  • Clinical evaluation of the signs and/or symptoms ascribed to the macromastia, therapies prior to reduction mammoplasty and the responses to these therapies.
    
    
  • The operative report with documentation of the weight of tissue removed from each breast, obtained in the operating room.
    
    
  • The pathology report of the tissue removed from each breast.

For abdominal lipectomy/panniculectomy: 

• The member's medical record must contain, and be available for review on request, the following information:
  
  
  • Description of the pannis and the underlying skin.
    
    
  • Description of conservative treatment undertaken and its results.
    

For Dermal injection:

• The member’s medical record must contain, and be available on request, the following information:
  
  
  • Conclusive evidence of the diagnosis of HIV and treatment with Highly Active Antiretroviral Therapy (HAART).
    
    
  • Description of facial abnormalities consistent with FLS.
    
    
  • Description of depressive symptoms and any treatment undertaken.

Provider News

04/2012, Medicare Advantage cosmetic and reconstructive surgery coverage criteria outlined

Covered Diagnosis Codes

The following is limited coverage for dermabrasion (15780, 15781, 15782 abd 15783):

The following is limited coverage for abdominal lipectomy/panniculectomy (codes 15830 and 15847):

The following is limited coverage for reconstructive breast surgery (codes 19316, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396):

The following is dual-diagnosis limited coverage for reduction mammoplasty (code 19318):

Covered for primary diagnosis:

Coverage for secondary diagnoses:

*Note: Use V58.42 to indicate a mammoplasty to reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery.

The following is limited coverage for rhinoplasty (codes 30400, 30410, 30420, 30430, 30435, 30450, 30460 and 30462):

*Effective 10/01/2011

Effective 10/01/2011, code 173.3 was deleted

The codes for dermal injections requires reporting three appropriate diagnoses. Report the primary diagnosis as 272.6 (Lipodystrophy). Report a secondary diagnosis from Table 1 and a tertiary diagnosis from Table 2 below. The following lists include only those diagnoses for which the identified procedures are covered.

The following is limited coverage for Dermal injections (codes C9800, G0429, Q2026 and Q2027):

Table 1: Secondary Diagnosis:

Table 2: Tertiary Diagnosis

The following diagnosis codes are non-covered when billed with any procedure or diagnosis code, not just those included in this policy: