Pending Policies - Surgery


Cosmetic and Reconstructive Procedures

Number:SUR716.001

Effective Date:01-01-2018

Coverage:

*CAREFULLY CHECK STATE REGULATIONS AND/OR THE MEMBER CONTRACT*

This medical policy does NOT address Gender Reassignment Services (Transgender Services). This medical policy IS NOT TO BE USED for Gender Reassignment Services. Refer to SUR717.001, Gender Assignment Surgery and Gender Reassignment Surgery and Related Services

NOTE 1:

For coverage of specific procedures please see the specific medical policy where indicated.

NOTE 2: 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.

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.

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 SUR716.009

See Medical Policy SUR716.009

Blepharoplasty.

See Medical Policy SUR716.004

See Medical Policy SUR716.004

Chemical Peels.

See Medical policy SUR716.018

See Medical policy SUR716.018

Cool sculpting (may also be known as cryolipolysis or fat freezing)

Experimental, investigational, and/or unproven for all indications.

Experimental, investigational, and/or unproven for all indications.

Congenital Anomaly.

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

Over the age of 19.

Fractional ablative laser fenestration for functional improvement of scars.

Experimental, investigational, and/or unproven for all indications.

Experimental, investigational, and/or unproven for all indications.

Gynecomastia.

See Medical policy SUR716.017

See Medical policy SUR716.017

Hair Transplant (Hairplasty).

For permanent alopecia as a result of trauma.

For male pattern alopecia,

For alopecia due to disease or therapeutic procedures. CHECK CONTRACTS FOR COVERAGE ELIGIBILITY

Injectable Implant.

Prolaryn™ Plus and Prolaryn™ Gel (formerly known as Radiesse Laryngeal Implant); Juliesse TM Laryngeal Implant, Coaptite™ Laryngeal Augmentation System, or Laryngeal Augmentation 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 SUR716.011

See Medical Policy SUR716.011

Mammaplasty, reduction.

See Medical Policy SUR716.012

See Medical Policy SUR716.012

Mandibular or maxillary resection.

See Medical Policies SUR705.010

SUR705.030

SUR706.009

See Medical Policies SUR705.010

SUR705.030

SUR706.009

Mastectomy.

See Medical Policy SUR716.015

See Medical Policy SUR716.015

Mastectomy Simple or Prophylactic.

See Medical Policy SUR716.015

See Medical Policy SUR716.015

Mastectomy Subcutaneous.

See Medical policy SUR716.015

See Medical policy SUR716.015

Mastopexy.

See Medical Policy SUR716.010

See Medical Policy SUR716.010

Mentoplasty, Genioplasty or chin implant.

Cosmetic for all indications.

Cosmetic for all indications.

Mesotherapy-Injection for Lipolysis.

Cosmetic for all indications.

Cosmetic for all indications.

Neurofibromas, cutaneous destruction.

When the following conditions exist that may interfere with normal function such as:

Symptomatic neurofibromas (painful, tender, infected).

Destruction of cutaneous neurofibromas that do not interfere with normal function.

Obesity.

See Medical Policy SUR716.003

See Medical Policy SUR716.003

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 THE801.027

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 SUR704.008

See Medical Policy SUR704.008

Psoriasis.

See Medical Policy THE801.033

See Medical Policy THE801.033

Refractive keratoplasty.

See Medical Policy SUR713.001

See Medical Policy SUR713.001

Restoration of body form.

Refer to SUR717.001 for Gender Assignment Surgery and Gender Reassignment Surgery with Related Services

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;

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 SUR706.001

See Medical Policy SUR706.001

Rhytidectomy

For treatment of burns.

For treatment of the face for aging skin.

Sclerotherapy

See Medical Policy SUR707.016

See Medical Policy SUR707.016

Septoplasty

See Medical Policy SUR706.001

See Medical Policy SUR706.001

Submental fat in adults (i.e., double chin) treated with Kybella TM (deoxycholic acid) injections.

Cosmetic for all indications.

Cosmetic for all indications.

Suction Assisted Lipectomy or body contouring with silicone or liposuction.

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

See Medical Policy SUR716.011

Suction assisted lipectomy, by any method.

See Medical Policy SUR716.011

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.

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.

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.

Lasers

Lasers, including CO2 surgical lasers, may be used for a variety of indications that include both functional and aesthetic applications. To date, there is inadequate published peer reviewed literature to permit conclusions regarding health outcomes in functional improvement of scars with the treatment of ablative fractional laser resurfacing. (17, 18) Well-conducted long term randomized controlled trials (RCTs) with sufficiently large sample sizes are needed to draw conclusions on the impact to health outcomes.

Contract:

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.

Coding:

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

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.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

11200, 11201, 11920, 11921, 11922, 11950, 11951, 11952, 11954, 11960, 11970, 15775, 15776, 15780, 15781, 15782, 15783, 15786, 15787, 15824, 15825, 15826, 15828, 15829, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879, 17380, 19355, 21120, 21121, 21122, 21123, 21740, 21742, 21743, 31572, 31573, 31574, 54660, 69090, 69300, 0419T, 0420T, 0479T, 0480T

HCPCS Codes

G0429, J3490, L8607, Q2026, Q2028, [Deleted 1/2017: C9742]

ICD-9 Diagnosis Codes

Refer to the ICD-9-CM manual

ICD-9 Procedure Codes

Refer to the ICD-9-CM manual

ICD-10 Diagnosis Codes

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does have a national Medicare coverage position.

A national coverage position for Medicare may have been changed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.

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.” (Amended by the Board of Directors August 7, 2010) Available at:<http//www.addassociation.org> (accessed January 30, 2017).

2. Reconstructive/Cosmetic Services (Archived). Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2003 Mar) Administrative 10.01.09.

3. 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. Available at: <http://www.accessdata. fda.gov> (accessed January 30, 2017).

4. 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. Available at: <http://www.accessdata. fda.gov> (accessed January 30, 2017).

5. 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. Available at: <http://www.accessdata. fda.gov> (accessed January 30, 2017).

6. 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.

7. 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. Available at: <http://www.accessdata.fda.gov> (accessed January 30, 2017).

8. Department of Health and Human Services. Center for Devices and Radiological Health. Section 510(k) premarket notification. K070090 Radiesse Laryngeal Implant. Available at: <www.accessdata.fda.gov> (accessed January 30, 2017).

9. American Society of Plastic Surgeons (ASPS) Guiding Principles for Mesotherapy/Injection Lipolysis. ASPS Executive Committee, July 2008. Accessed at <www.plasticsurgery.org> Accessed 2-23-2015.

10. Amin, S., Phelps, R., Goldberg,D. Mesotherapy for facial skin rejuvenation: a clinical, histologic, and electron microscopic evaluation. Dermatol Surg. 2006 Dec; 32(12): 1467-72. PMID: 17199654.

11. Brown, S. The Science of Mesotherapy: Chemical Anarchy. Aesthetic Surgery Journal. Volume 26, Number 1, January/February 2006, pages 95-98. PMID: 19338891

12. Department of Health & Human Services. New Drug Application (NDA) Approval: NDA 206333 for KybellaTM (deoxycholic acid) injection, 10mg/mL. Available at <http://www.accessdata.fda.gov> (accessed January 30, 2017).

13. KYTHERA Biophamaceuticals Announces FDA Approval of KYBELLATM April 29, 2015 Available at: <http://kythera.com.> (accessed June 21, 2016).

14. Neurofibromatosis Fact Sheet. National Institute of Neurological Disorders and Stroke. Available at <http://www.ninds.nih.gov> (accessed January 30, 2017).

15. Jaroszewski, D., Notrica, D., McMahon, L., et al. Clinical reviews Current Management of Pectus Excavatum: A review and update of Therapy and Treatment Recommendations. J Am Board Fam Med. March-April 2010; 23(2):230-9. PMID: 20207934

16. Ingargoila, M., Motakef, S., Chung, M., et al. Cryolipolysis for fat reduction and body contouring: Safety and efficacy of current treatment paradigms. Plast Reconstr Surg. 2015 Jun; 135(6): 1581-90. PMID: 26017594.

17. Krakowski A, Goldenberg A, Eichenfield L, et al. Ablative fractional laser resurfacing helps treat restrictive pediatric scar contractures. Pediatrics. 2014 Dec; 134(6): e1700-5. PMID 25367535

18. Shumaker p, Kwan J, Landers J, et al. functional improvement in traumatic scars and scar contractures using an ablative fractional laser protocol. J Trauma Acute Care Surg. 2012 Aug; 73(2 Suppl 1): S116-21. PMID 22847080

Policy History:

Date Reason
1/1/2018 Document updated with literature review. The following change was made to Coverage: 1) Added “Fractional ablative laser fenestration for functional improvement of scars is considered experimental, investigational, and/or unproven for all indications.”
7/1/2017 Document updated with literature review. The following was added to coverage: Cool sculpting (may also be known as cryolipolysis or fat freezing) is considered experimental, investigational, and/or unproven for all indications. The following was removed from the coverage section: Relume™ for treatment of Stretch Marks.
8/15/2016 Document updated with literature review. Coverage under Injectable Implant section, had Juliessa changed to Juliesse TM . Under the Reconstructive section and under the Cosmetic section Prolaryn TM gel (formerly known as Radiesse or Juliessa Laryngeal Implant) was removed and replaced by Radiesse.
1/1/2016 The following was added to the Coverage section: Neurofibromas, cutaneous destruction is considered reconstructive when the following conditions exist that may interfere with normal function such as: symptomatic neurofibromas (painful, tender, infected); destruction of cutaneous neurofibromas that do not interfere with normal function are considered cosmetic.
9/15/2015 Medical document updated with literature review. The following was added to the coverage section: Mesotherapy-Injection for Lipolysis, is considered cosmetic for all indications and Submental fat in adult (i.e., double chin) treated with Kybella TM (deoxycholic acid) injections is considered cosmetic for all indications.
8/15/2013 Medical document updated with literature review. The following was added to the “Coverage” section under “Injectable Implant” – “Radiesse Laryngeal Implant for indications of vocal fold medialization and vocal fold insufficiency in accordance with FDA labeling” found under the “Reconstructive” column in the “Clinical Conditions/Reconstructive/Cosmetic” table. The following was removed “This policy is no longer scheduled for routine literature review and update.”
1/15/2012 Medical document updated with literature review. The following was added: EGRIFTA is considered cosmetic for all indications, including, but not limited to the reduction of excess abdominal fat in the HIV-infected patients with lipodystrophy.
3/15/2011 Medical document updated. The coverage of Radiesse® was expanded by adding the following: Radiesse is considered cosmetic 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.
4/15/2009 Coverage revised to allow testicular prosthesis after orchiectomy for reconstruction after malignancy.
3/15/2008 Revised/updated entire document. This policy is no longer scheduled for routine literature review and update.
2/15/2008 Coverage revised
9/15/2007 Coverage revised
3/15/2007 Revised/updated entire document
10/15/2006 Revised/updated entire document
3/1/2006 Revised/updated entire document
8/1/2005 Revised/updated entire document
11/1/1999 Revised/updated entire document
9/1/1999 Revised/updated entire document
5/1/1996 Revised/updated entire document
7/1/1994 Revised/updated entire document
1/1/1993 Revised/updated entire document
10/1/1992 Revised/updated entire document
5/1/1990 New medical document

Archived Document(s):

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