Download Cosmetic, Plastic and Scar Revision Surgery

Clinical Policy Title: Cosmetic, plastic and scar revision surgery
Clinical Policy Number: 16.03.08
Effective Date:
Initial Review Date:
Most Recent Review Date:
Next Review Date:
October 1, 2015
August 19, 2015
August 19, 2015
August 2016
Policy contains:
 Cosmetic surgery.
 Plastic (reconstructive) surgery.
 Scar revision.
Related policies:
CP# 10.03.01
CP# 11.03.01
CP# 16.03.05
CP# 16.03.07
Blepharoplasty
Neonatal circumcision in males
Breast reduction surgery
Mastectomy for male gynecomastia
ABOUT THIS POLICY: AmeriHealth Caritas Pennsylvania has developed clinical policies to assist with making coverage determinations.
AmeriHealth Caritas Pennsylvania’s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare &
Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peerreviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory
requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered
by AmeriHealth Caritas Pennsylvania when making coverage determinations. In the event of conflict between this clinical policy and plan benefits
and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall
control. AmeriHealth Caritas Pennsylvania’s clinical policies are for informational purposes only and not intended as medical advice or to direct
treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas
Pennsylvania’s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas
Pennsylvania will update its clinical policies as necessary. AmeriHealth Caritas Pennsylvania’s clinical policies are not guarantees of payment.
The purpose of this policy is to supplement coverage guidance for surgical procedures with cosmetic
aspects that may not be contained in a separate clinical policy.
Coverage policy
AmeriHealth Caritas Pennsylvania considers plastic (also called reconstructive) surgery to be medically necessary
when:

The need for the surgical procedure is clinically proven.
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
The goal of surgery is to correct functional impairment of a body area caused by a congenital
defect, developmental abnormality, trauma, burns, infection, tumors or disease.

AmeriHealth Caritas Pennsylvania considers revision of scar tissue to be medically necessary if it
is required to correct an objective functional impairment and the scar resulted from an
accidental injury or a medically necessary surgical procedure.
Limitations:
 AmeriHealth Caritas Pennsylvania considers surgery performed to improve body appearance in
the absence of a functional impairment to be cosmetic and, therefore, not medically necessary.

AmeriHealth Caritas Pennsylvania considers surgical revision of scar tissue caused by a cosmetic
procedure or otherwise non-covered procedures to be cosmetic and, therefore, not medically
necessary.
All requests for coverage of plastic surgery of a non-Medicare member require prior review by a medical
director on a case-by-case basis, except for those procedures addressed in another clinical policy or
required by state or federal authorities. See Related policies on page 1 of this policy.
Note: The following CPT code is not included in the Pennsylvania Medicaid fee schedule:
15830 - Excision, excessive skin and subcutaneous tissue (including lipectomy); abdomen infraumbilical
panniculectomy [documentation required] [not covered for aesthetic operations on umbilicus]
For Medicare members only:
AmeriHealth Caritas Pennsylvania considers plastic surgery procedures to be clinically proven and,
therefore, medically necessary for medical indications identified in the following applicable Local Coverage
Determinations (LCDs) for cosmetic and reconstructive surgery: L30733, L31784 and L30733, listed later in
this policy.
These claims are reviewed by medical staff and considered on a case-by-case basis. Medical records are
requested by the contractor to determine medical necessity. See Documentation Requirements for each
LCD.
Alternative covered services:
Prescription drug therapy may be appropriate for certain conditions.
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Background
While both cosmetic surgery and plastic surgery deal with improving a patient’s body, the overarching
philosophies guiding the training, research and goals for patient outcomes are different (American Board of
Cosmetic Surgery [ABCS], 2015; American Society of Plastic Surgery [ASPS], 2015).
Cosmetic surgical procedures, techniques and principles are entirely focused on reshaping normal
structures of the body to improve aesthetic appeal, symmetry and proportion in a person’s appearance.
Because the treated areas function properly, cosmetic surgery is elective. Cosmetic surgery is practiced by
doctors from a variety of medical fields, including plastic surgeons (ABCS, 2015; ASPS, 2015).
Plastic surgery is a surgical specialty dedicated to correcting dysfunctional areas of the face and body
caused by congenital defects, developmental abnormalities, trauma, burns, infection, tumors and disease
(ABCS, 2015; ASPS, 2015). It is generally performed to improve function, but may also be done to
approximate a normal appearance. While many plastic surgeons choose to complete additional training and
perform cosmetic surgery, the basis of their surgical training remains reconstructive surgery (ABCS, 2015;
ASPS, 2015).
Scar tissue may form as skin heals after an injury or surgery. The amount of scarring is determined by
factors such as the size, depth and location of the wound; the age of the person; heredity; and skin
characteristics, including color (pigmentation). Scar revision may be performed to correct, remove or
improve scar tissue (ASPS, 2015).
The field of plastic surgery continuously strives for innovation to provide the highest quality of care.
Evidence-based medicine (EBM) integrates the best research evidence with clinical expertise and patient
values, but, until recently, the specialty was slow to adopt EBM (Chung, 2009; Burns, 2011). So both
established and novel practices are often adopted without sufficient data supporting their safety or efficacy
(Chung, 2009; Ayeni, 2012; Agha, 2013). The ASPS actively promotes EBM to encourage publication of
higher-quality evidence from well-designed, randomized controlled trials, cohort studies, case-control
studies, systematic reviews and, if possible, meta-analyses of plastic surgery technologies and treatments
(Chung, 2009; Burns, 2011). Going forward, this will ensure improvement in the best available evidence on
which decisions permitting use of plastic surgical procedures can be based.
Searches
AmeriHealth Caritas Pennsylvania searched PubMed and the databases of:
 UK National Health Services Centre for Reviews and Dissemination.
 Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other evidencebased practice centers.
 The Centers for Medicare & Medicaid Services (CMS).
We conducted searches on August 9, 2015. Search terms were: “cosmetic surgery (MeSH),” and
"Reconstructive Surgical Procedures (Mesh).”
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We included descriptive articles, guidelines and regulatory documents relevant to this policy.
Findings
N/A
CMS Policy
CMS LCDs: Cosmetic and
Reconstructive Surgery
(L30733, L31784, L30733)
Key points:
Summary of indications for
specific surgical procedures
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3.
Breast reconstruction of the affected and the contralateral unaffected breast following a
medically necessary mastectomy is covered.
Removal or revision of a breast implant is considered medically necessary when it is removed
for one of the following reasons:
 Mechanical complication of breast prosthesis — including rupture or failed implant
and/or implant extrusion.
 Infection or inflammatory reaction due to a breast prosthesis — including infected breast
implant or rejection of breast implants.
 Other complication of internal breast implant — including siliconoma, granuloma,
interference with diagnosis of breast cancer and/or painful capsular contracture with
disfigurement.
Reduction mammoplasty is the surgical reshaping of the breasts to reduce or lift enlarged or
sagging breasts.
 Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare
benefit.
 Macromastia (breast hypertrophy) is an increase in the volume and weight of breast
tissue relative to the general body habitus. Breast hypertrophy may adversely affect
other body systems: musculoskeletal, respiratory and integumentary. Unilateral
hypertrophy may result in symptoms following contralateral mastectomy.
 Medical necessity for a reduction mammoplasty is limited to circumstances in which:
o There are signs and/or symptoms resulting from the enlarged breasts
(macromastia) that have not responded adequately to nonsurgical
interventions.
o Reducing the size of a normal breast to bring it into symmetry with a breast
reconstructed after cancer surgery.
 Nonsurgical interventions preceding reduction mammoplasty should include as
appropriate, but are not limited to, the following:
o Determining the macromastia is not due to an active endocrine or metabolic
process.
o 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.
o Determining that dermatologic signs and/or symptoms are refractory to, or
recurrent following, a completed course of medical management.
 A medically 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:
o Back, neck and/or shoulder pain from macromastia and unrelieved by six
months of:
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10.
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 Conservative analgesia.
 Supportive measures (e.g., garment).
 Physical therapy.
o Significant arthritic changes in the cervical or upper thoracic spine, optimally
managed with persistent symptoms and/or significant restriction of activity.
o Intertriginous maceration or infection of the inframammary skin refractory to
dermatologic measures.
o Permanent shoulder grooving with skin irritation by supporting garment (bra
strap).
Mastectomy for gynecomastia (19300):
Gynecomastia is the excessive growth of the male mammary glands. These conditions can
cause significant clinical manifestations when the excessive breast weight adversely affects
the supporting structures of the shoulders, neck and trunk. Payment may be made for this
procedure if it is documented that the tissue is primarily breast tissue and not just adipose
(fatty tissue).
Tattooing to correct color defects of the skin may be considered reconstructive when
performed in connection with a payable postmastectomy reconstruction, or for reconstruction
following trauma or removal of cancer from an eyelid, eyebrow or lip(s).
Punch graft hair transplant may be considered reconstructive when it is performed for
eyebrow replacement following a burn injury or tumor removal.
Rhinoplasty performed to improve nasal respiratory function due to airway obstruction or
stricture, repair deficits caused by trauma, revise structural deformities produced by trauma or
nasal cutaneous disease, or replace nasal tissue lost after tumor ablative surgery is covered.
Nasal fracture.
Benign or malignant neoplasms.
Nasal obstruction.
Chemical peel is covered for the treatment of actinic keratosis.
Dermabrasion, segmental; face is covered for the treatment of rhinophyma.
Dermal injections for facial LDS using dermal fillers approved by the U.S. Food and Drug
Administration for this purpose, and then only in HIV-infected Medicare beneficiaries who
manifest depression secondary to the physical stigma of HIV treatment will be covered.
Effective for claims with dates of service on and after March 23, 2010. See Pub. 100-03, Medicare
National Coverage Determinations Chapter 1, Coverage Determinations Part 4, Section 250.5, for
specific coverage criteria. See Pub. 100-04, Claims Processing Manual, Chapter 32, Section 260,
for specific claims payment/coding instructions.
The following procedures will be considered on an individual basis:
1. Rhytidectomy, is considered medically necessary to correct a functional impairment as a
result of a disease state, i.e., facial paralysis. Often this procedure is performed in conjunction
with other procedures to correct the impairment.
2. Excision, excessive skin and subcutaneous tissue (including lipectomy); abdomen
(abdominoplasty) will only be considered reasonable and medically necessary when these
procedures are performed due to another surgery performed at the same time and would
affect the healing of the surgical incision.
3. This procedure may also be considered medically necessary for the patient that has had
significant weight loss following the treatment of morbid obesity with medical complications
such as candidiasis, intertrigo or tissue necrosis unresponsive to oral or topical medication.
These claims will be reviewed by the medical staff and considered on a case-by-case basis.
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Medical records will be requested by the contractor to determine medical necessity. See
Documentation Requirements section of this LCD.
Glossary
Cosmetic surgery — Per CMS this surgery is a “procedure that is performed to reshape normal structures of
the body to improve the patient's appearance and self-esteem. These procedures can be performed for
medically necessary or cosmetic reasons.” Cosmetic surgery is a subspecialty of plastic surgery.
Functional impairment — A direct and measurable reduction in physical performance of an organ or body
part.
Medically necessary — A classification of service or benefit if it is compensable, preventive of illness onset
or reductive of side effects, or it maximizes functional capacity.
Plastic (reconstructive) surgery — Per CMS this 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.”
References
Professional society guidelines/other:
None.
Peer-reviewed references:
Agha RA, Camm CF, Edison E, Orgill DP. The methodological quality of randomized controlled trials in plastic
surgery needs improvement: a systematic review. J Plast Reconstr Aesthet Surg. Apr 2013;66(4):447 – 452.
Ayeni O, Dickson L, Ignacy TA, Thoma A. A systematic review of power and sample size reporting in
randomized controlled trials within plastic surgery. Plast Reconstr Surg. Jul 2012;130(1):78e – 86e.
Burns PB, Rohrich RJ, Chung KC. The Levels of Evidence and their role in Evidence-Based Medicine. Plast
Reconstr Surg. 2011;128(1):305 – 310.
Chung KC, Swanson JA, Schmitz D, Sullivan D, Rohrich RJ. Introducing evidence-based medicine to plastic
and reconstructive surgery. Plastic and reconstructive surgery. Apr 2009;123(4):1385 –1389.
Cosmetic Surgery vs. Plastic Surgery. The American Board of Cosmetic Surgery.
http://www.americanboardcosmeticsurgery.org/patient-resources/cosmetic-surgery-vs-plastic-surgery/.
Accessed August 9, 2015.
The American Society of Plastic Surgeons. http://www.plasticsurgery.org/. Accessed August 9, 2015.
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Kowalski E, Chung KC. The outcomes movement and evidence-based medicine in plastic surgery. Clin Plast
Surg. Apr 2013;40(2):241 – 247.
Clinical trials:
CMS National Coverage Determinations (NCDs):
No NCDs identified as of the writing of this policy.
Local Coverage Determinations (LCDs):
Cosmetic and Reconstructive Surgery (L30733). 13 individual LCDs. https://www.cms.gov/medicarecoverage-database/details/lcd-details.aspx?LCDId=31784&ver=37&ContrId=235&ContrVer=1. Accessed
August 9, 2015.
Cosmetic and Reconstructive Surgery (L32763). 14 individual LCDs. https://www.cms.gov/medicarecoverage-database/details/lcd-details.aspx?LCDId=32763&ver=45&ContrId=339&ContrVer=1. Accessed
August 9, 2015.
Cosmetic and Reconstructive Surgery (L31784). Four individual LCDs. https://www.cms.gov/medicarecoverage-database/details/lcd-details.aspx?LCDId=31784&ver=37&ContrId=235&ContrVer=1. Accessed
August 9, 2015.
Commonly submitted codes
Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not
an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill
accordingly.
CPT Code
Description
11920 – 11922
Tattooing, intradermal introduction of insoluble opaque pigments to correct
color defects of skin, including micropigmentation
11950 – 11954
Subcutaneous injection of filling material (e.g., collagen)
15780 – 15782
Dermabrasion; total face (e.g., for acne scarring, fine wrinkling, rhytids,
general keratosis); segmental, face; or regional, other than face
15788 – 15793
Chemical peel
15830
Comment
Excision, excessive skin and subcutaneous tissue (including lipectomy);
abdomen infraumbilical panniculectomy [documentation required] [not
covered for aesthetic operations on umbilicus]
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15840 – 15845
15877
Graft for facial nerve paralysis
Suction assisted lipectomy; trunk [covered for medically necessary breast
reconstruction and hyperhidrosis only]
17106 – 17108
Destruction of cutaneous vascular proliferative lesions (e.g., laser
technique)
19318 – 19350,
19357 – 19396
Repair and/or reconstruction of breast [except breast lift (mastopexy)][not
covered to repair tuberous breast deformity]
20926
21740 – 21743
30120
30420, 30435,
30450, 30460,
30462
Tissue grafts, other (e.g., paratenon, fat, dermis) [covered for medically
necessary breast reconstruction only]
Reconstructive repair of pectus excavatum or carinatum
Excision or surgical planing of skin of nose for rhinophyma
Rhinoplasty
30520
Septoplasty or submucous resection, with or without cartilage scoring,
contouring or replacement with graft
54660
Insertion of testicular prosthesis (separate procedure)
ICD 9 Code
Extensive list
ICD 10 Code
Extensive list
Description
Comment
Use an applicable ICD 9 code based on procedure performed
Description
Comment
Use an applicable ICD 10 code based on procedure performed
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