Download cosmetic and reconstructive procedures

COSMETIC AND RECONSTRUCTIVE
PROCEDURES
Protocol: SUR040
Effective Date: March 1, 2016
Table of Contents
Page
COMMERCIAL COVERAGE RATIONALE.......................................................................................... 1
COMMERCIAL COVERAGE: REQUIRED DOCUMENTATION ....................................................... 3
MEDICARE COVERAGE RATIONALE .............................................................................................. 12
MEDICAID COVERAGE RATIONALE ............................................................................................... 16
DEFINITIONS ........................................................................................................................................ 16
APPLICABLE CODES – COMMERCIAL ............................................................................................ 22
APPLICABLE CODES – MEDICARE .................................................................................................. 28
REFERENCES ........................................................................................................................................ 39
PROTOCOL HISTORY/REVISION INFORMATION ......................................................................... 42
INSTRUCTIONS FOR USE
This protocol provides assistance in interpreting UnitedHealthcare benefit plans. When deciding
coverage, the enrollee specific document must be referenced. The terms of an enrollee's document
(e.g., Certificate of Coverage (COC) or Evidence of Coverage (EOC)) may differ greatly. In the event
of a conflict, the enrollee's specific benefit document supersedes this protocol. All reviewers must first
identify enrollee eligibility, any federal or state regulatory requirements and the plan benefit coverage
prior to use of this Protocol. Other Protocols, Policies and Coverage Determination Guidelines may
apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Protocols, Policies and
Guidelines as necessary. This protocol is provided for informational purposes. It does not constitute
medical advice. This policy does not govern Medicare Group Retiree members.
UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines,
to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in
connection with the independent professional medical judgment of a qualified health care provider and
do not constitute the practice of medicine or medical advice.
For further information see:
Protocol SUR018 – BREAST REDUCTION SURGERY
Protocol SUR050 – BLEPHAROPLASTY, BLEPHAROPTOSIS & BROW PTOSIS REPAIR
COMMERCIAL COVERAGE RATIONALE
A procedure is cosmetic and considered not medically necessary when the primary purpose is to
change or improve appearance in the absence of specific functional deficit(s) that can be removed or
Cosmetic and Reconstructive Procedures
Page 1 of 42
improved by the procedure.
A procedure is considered reconstructive and medically necessary when the primary purpose is to
restore or improve physiologic function when a physical impairment exists.
A procedure may be considered reconstructive and medically necessary when it is intended to correct
a congenital malformation that is likely to cause future functional impairment.
When reviewing an individual case it is important to determine the primary reason for the surgery and
to understand how the proposed surgery will affect the function of the body part.
Cosmetic Procedures are excluded from coverage. Except for reconstructive surgery following a
mastectomy, cosmetic procedures to improve appearance without restoring a bodily function are
excluded. Cosmetic procedures include:
•
•
•
•
Surgery for sagging or extra skin,
Any augmentation or reduction procedures,
Rhinoplasty and associated procedures, and
Any procedure utilizing an implant which does not alter physiologic functions unless medically
necessary.
Psychological factors (example: for self-image, difficult social or peer relations) do not constitute
restoring a physical bodily function and are not relevant to such determinations. (HPN Generic
Evidence of Coverage, 2012)
Reconstructive procedures are performed to restore or improve physiologic function when a physical
impairment exists. Reconstructive procedures are procedures that are performed incidental to an injury,
sickness, or congenital anomaly when the primary purpose is to improve or restore physiological
functioning of the impaired part of the body. A congenital/developmental malformation may cause a
future physiological functional impairment even when such impairment does not exist at birth. The fact
that physical appearance may change or improve as a result of reconstructive surgery does not classify
such surgery as cosmetic when a functional impairment exists, and the surgery restores or improves
function.
While surgery on the female breast following mastectomy does not facilitate or improve lactation, it is
generally considered reconstructive surgery when done on either the ipsilateral or contralateral side.
The following are examples of reconstructive services:
• Breast reconstruction following a mastectomy and reconstruction of the non-affected breast to
achieve symmetry. (Women's Health Care Act of 1998).
• Surgical treatment to repair craniosynostosis for the treatment of children with early closure of
skull sutures. (See Protocol ORT010: Plagiocephaly & Craniosynostosis)
• Surgery to correct cleft lip, cleft palate, or combinations of the two. (See Protocol ENT001:
Cleft Lip &/or Cleft Palate Repair)
Cosmetic and Reconstructive Procedures
Page 2 of 42
•
This list is necessarily incomplete.
COMMERCIAL COVERAGE: REQUIRED DOCUMENTATION
Cosmetic Procedures are excluded from coverage. Refer to the procedure specific Healthcare
Operations Protocol for additional information, including criteria for coverage and specific clinical
information/documentation required to make a coverage determination.
BREAST REPAIR/RECONSTRUCTION POST MASTECTOMY
Indications for coverage
Breast reconstruction is covered for enrollees who have a mastectomy with or without a diagnosis of
cancer. Mastectomy includes partial (lumpectomy, tylectomy, quadrantectomy, and segmentectomy),
simple, and radical. This benefit does not include aspirations, biopsy (open or core), excision of cysts,
fibroadenomas or other benign or malignant tumors, aberrant breast tissue, duct lesions, nipple or
areolar lesions, or treatment of gynecomastia.
There is not a time frame in which the enrollee is required to have the reconstruction done post
mastectomy under the Women’s Health and Cancer Rights Act of 1998.
1. In accordance with Federal and State mandates the following services are covered:
• Reconstruction of the breast on which the mastectomy was performed
• Surgery and reconstruction of the other breast to produce a symmetrical appearance,
including nipple tattooing
• Prosthesis (implanted and/or external)
• Treatment of physical complications of mastectomy, including lymphedema
Various surgical techniques are used for breast reconstruction, including but not limited to:
• Insertion of FDA approved breast implants and tissue expanders
• Breast implants and tissue expanders post mastectomy with or without skin substitutes,
approved by the FDA, including but not limited to : Alloderm, Allomax or FlexHD are a
covered benefit
• Transverse Rectus Abdominus Myocutaneous Flap (TRAM)
• Latissimus Dorsi Flap (LD)
• Deep Inferior Epigastric Perforator (DIEP) Flap
• Gluteal Flap (GAP free flap)
Refer to the Definitions Section of this protocol for breast reconstruction procedure definitions.
If the original implant or reconstructive surgery was considered reconstructive surgery under the Health
Plan benefit document, coverage may exist for removal, replacement, and/or reconstruction. If the
original implant or reconstructive surgery was considered reconstructive surgery under the health plan
benefit document, then removal of a ruptured prosthesis is treating a "complication arising from a
Cosmetic and Reconstructive Procedures
Page 3 of 42
medical or surgical intervention." Removal or replacement of an implant that is not ruptured and
unassociated with local breast complications may not be covered.
Additional Information:
A gap exception may be granted if there is not an in-network provider able to provide the requested
reconstructive procedure. Refer to the enrollee specific plan document for information regarding
coverage from non-network providers.
Breast reconstruction may be covered under certain circumstances for the surgical treatment of gender
dysphoria. Please refer to the enrollee specific benefit document for coverage.
Treatments for Complications Post Mastectomy:
1. Lymphedema:
a. Complex Decongestive Physiotherapy (CDP) is covered for the complication of
lymphedema post-mastectomy.
b. Lymphedema pumps when required are covered (when covered, these pumps are
covered as durable medical equipment).
c. Compression lymphedema sleeves are covered (when covered, these sleeves are
covered as a prosthetic device).
d. Elastic bandages and wraps associated with covered treatments for the complications of
lymphedema
2. Treatment of a post-operative infection (s)
3. Removal of a ruptured breast implant (either silicone or saline) is reconstructive for implants
done post-mastectomy. Placement of a new breast implant will be covered if the original
implantation was done post-mastectomy or for a covered reconstructive health service.
Coverage Limitations and Exclusions
Please refer to enrollee’s state mandates and plan specific documents.
1. Insertion of breast implants or reinsertion of breast implants for the purpose of improving
appearance is a cosmetic procedure unless covered under a state or federal mandate.
 If the breast reconstruction has been successfully completed post mastectomy and the
enrollee chooses to enlarge their breasts for cosmetic reasons, this is considered a
cosmetic service and is not a covered health service
2. Breast reconstruction or scar revision after breast biopsy or removal of a cyst with or without a
biopsy usually does not meet the definition of a covered reconstructive health service. Refer to
the enrollee’s plan specific documents and state mandates.
3. Tissue protruding at the end of a scar (“dog ear”/standing cone), painful scars or donor site scar
revisions must be reviewed to determine if the procedure meets reconstructive guidelines.
Cosmetic and Reconstructive Procedures
Page 4 of 42
4. Liposuction other than to achieve breast symmetry during post mastectomy reconstruction is
considered cosmetic and is not a covered health service
5. Revision of prior reconstructed breast due to normal aging does not meet the definition of a
covered reconstructive health service.
6. Not medically necessary services
BREAST REPAIR/RECONSTRUCTION (NOT FOLLOWING MASTECTOMY)
Indications for Coverage
If the member’s condition meets the Women’s Health and Cancer Rights (WHCRA) criteria or
applicable state mandates regarding post mastectomy, please see the section above on Breast
Repair/Reconstruction Post Mastectomy.
Criteria for a Coverage Determination as Reconstructive:
A. Removal of breast implants with capsulectomy/capsulotomy for symptomatic capsular
contracture is considered reconstructive when the following criteria are met:
1. Baker grade III or IV capsular contracture;
Baker Grading System for Capsular Contracture
Grade I - breast is soft without palpable thickening
Grade II - breast is a little firm but no visible changes in appearance
Grade III - breast is firm and has visible distortion in shape
Grade IV - breast is hard and has severe distortion or malposition in shape; pain/discomfort
may be associated with this level of capsule contracture (ASPS, 2005).
2. Limited movement leading to an inability to perform tasks that involve reaching or
abduction. Examples include retrieving something from overhead, combing one’s hair,
reaching out or above to grab something to stabilize oneself.
B. Removal of a deflated saline breast implant shell is considered cosmetic unless the implants
were done post-mastectomy. See Breast Reconstruction Post Mastectomy section above.
C. Correction of inverted nipples is considered reconstructive when one of the following criteria
are met:
1.
Member meets the Women’s Health and Cancer Rights Act (WHCRA) criteria (see
Breast Reconstruction Post Mastectomy section above); or
2.
Documented history of chronic nipple discharge, bleeding, scabbing or ductal infection.
Note: Correction of congenital inverted nipples may be covered based on a state mandate or
the enrollee’s specific benefit document.
Cosmetic and Reconstructive Procedures
Page 5 of 42
D. Revision of a reconstructed (CPT Code 19380) breast is considered reconstructive when the
original reconstruction was done for mastectomy or other covered health service. See
Applicable Codes section below for a list of codes that meet the criteria for a reconstructed
breast.
E. Breast reconstruction done for Poland Syndrome (see definition below) is reconstructive.
Although no functional impairment may exist for the breast reconstruction for Poland
Syndrome, this has been deemed reconstructive surgery.
F. Removal of a ruptured silicone gel breast implant is covered regardless of the indication for the
initial implant placement.
Additional Information
Tissue protruding at the end of a scar (“dog ear”/standing cone), painful scars or donor site scar
revisions must be reviewed to determine if the procedure meets reconstructive guidelines.
Breast reconstruction may be covered under certain circumstances for the surgical treatment of
gender dysphoria. Please refer to the enrollee specific benefit document for coverage.
Coverage Limitations and Exclusions
Some states require benefit coverage for services that the health plan considers cosmetic procedures,
such as repair of external congenital anomalies in the absence of a functional impairment. Please
refer to the enrollee’s plan specific documents.
1. Cosmetic Breast Procedures are excluded from coverage.
a. Examples include by are not limited to:
i. Replacement of an existing breast implant if the earlier breast implant was
performed as a cosmetic procedure (replacement of an existing breast
implant is considered reconstructive if the initial breast implant followed
mastectomy)
ii. Breast reduction surgery that is determined to be a cosmetic procedure. This
exclusion does not apply to breast reduction surgery which we determine is
requested to treat a physiologic functional impairment or to coverage required
by the Women’s Health and Cancer Right’s Act
iii. Breast surgery only for the purpose of creating symmetrical breasts except
when post mastectomy.
iv. Breast prosthetics or replacement following a cosmetic breast augmentation
2. Revision of a prior reconstructed breast due to normal aging does not meet the definition of a
covered reconstructive health service.
GYNECOMASTIA
Indications for Coverage
Criteria for a Coverage Determination that surgery is reconstructive and medically necessary:
Cosmetic and Reconstructive Procedures
Page 6 of 42
I. Mastectomy or suction lipectomy for treatment of benign gynecomastia for a male patient under age 18
is considered reconstructive and medically necessary when all the following criteria are met:
A. Gynecomastia or breast enlargement with moderate to severe chest pain that is causing a
functional/physical impairment as defined below in the Definitions section. The inability to
participate in athletic events, sports or social activities is not considered to be a
functional/physical or physiological impairment.
B. No prior history of prescribed medications and appropriate screening(s) of nonprescription
and/or recreational drugs or substances that have a known side effect of gynecomastia.
(examples include but are not limited to the following, testosterone, marijuana, asthma drugs,
phenothiazines, anabolic steroids, cimetidine and calcium channel blockers)
C. The breast enlargement must be present for at least 2 years. If so, lab tests which might include,
but are not limited to the following must be performed:
1. thyroid function studies;
2. testosterone;
3. Beta subunit HCG
II. Mastectomy or suction lipectomy for treatment of benign gynecomastia for a male patient age 18 and
up is considered reconstructive and medically necessary when all the following criteria are met:
A. Discontinuation of medications, nutritional supplements, and non-prescription medications or
substances (examples include but are not limited to the following, testosterone, marijuana,
asthma drugs, phenothiazines, anabolic steroids, cimetidine and calcium channel blockers) that
have a known side effect of gynecomastia or breast enlargement and the breast size did not
regress after discontinuation of use as appropriate.
B. Gynecomastia or breast enlargement with moderate to severe chest pain that is causing a
functional/physical impairment as defined below in the Definitions section. The inability to
participate in athletic events, sports or social activities is not considered to be a
functional/physical or physiological impairment.
C. Review of test results that have been performed to rule out certain diseases or other causes of
gynecomastia ( examples include but are not limited to blood tests, e.g. hormone levels
estrogen, testosterone, liver and kidney function studies/enzymes)
D. Glandular breast tissue is the primary cause of gynecomastia as opposed to fatty deposits and is
documented on physical exam and/or mammography.
Additional Information:
In most cases breast enlargement and/or benign gynecomastia spontaneously resolves by age 18
making treatment unnecessary. Gynecomastia during puberty is not uncommon and in 90% of cases
regresses within 3 years of onset.
If a tumor or neoplasm is suspected, a breast ultrasound and/or mammogram may be performed. As
indicated, a breast biopsy may also be performed.
Cosmetic and Reconstructive Procedures
Page 7 of 42
Coverage Limitations and Exclusions
1.
Treatment of benign gynecomastia when specifically excluded in the enrollee specific benefit
document.
2.
Treatment of benign gynecomastia when not specifically excluded in the enrollee specific
benefit document and the above criteria is not met.
3.
Most medical and surgical treatments for benign gynecomastia are considered cosmetic.
Medical treatments and surgery to alter a perceived abnormal appearance, or for psychological
reasons, are considered cosmetic and are not covered. The fact that a Covered Person may suffer
psychological consequences or socially avoidant behavior as a result of benign gynecomastia
does not classify surgery (or other procedures done to relieve such consequences or behavior) as
a reconstructive procedure.
PANNICULECTOMY & BODY CONTOURING PROCEDURES
Requirements for Coverage
A. Panniculectomy is considered reconstructive and medically necessary when ALL of the following
criteria have been met:
1. Panniculus hangs at or below symphysis pubis;
2. The panniculus is the primary cause of skin conditions when present, such as cellulitis
requiring systemic antibiotics or transdermal skin ulcerations that require medical treatment;
3. There is presence of a functional impairment due to the panniculus;
4. The surgery is expected to restore or improve the functional impairment;
5. The panniculus is interfering with activities of daily living.
Note:
• After significant weight loss not following bariatric surgery, in addition to the criteria
listed above, there must be documentation that a stable weight has been maintained for
six months.
• After significant weight loss following bariatric surgery, in addition to meeting the
criteria listed above there must be documentation that a stable weight has been
maintained for six months. This often occurs 12 – 18 months after surgery.
B. Panniculectomy is not considered reconstructive, and is not a covered service, in the following
situations (not an all-inclusive list):
1. When performed to relieve neck or back pain as there is no evidence that reduction of
redundant skin and tissue results in less spinal stress or improved posture/alignment.
2. When performed in conjunction with abdominal or gynecologic surgery including but not
limited to hernia repair, obesity surgery, C-section and hysterectomy unless the enrollee
meets the criteria for panniculectomy as stated above in this document.
3. Performed post childbirth in order to return to pre-pregnancy shape.
Cosmetic and Reconstructive Procedures
Page 8 of 42
4. Performed for intertrigo, a superficial inflammatory response or any other condition that
does not meet the criteria above in this document.
Documentation may be requested as part of the review, including but not limited to photographs
and physician office notes.
C. Abdominoplasty is not considered reconstructive, and is not a covered service, in the following
situations (not an all-inclusive list):
1. Performed post childbirth in order to return to pre-pregnancy shape.
2. Performed for diastasis recti.
3. When performed in conjunction with abdominal or gynecologic surgery including but not
limited to hernia repair, obesity surgery, C-section and hysterectomy.
4. No documentation of a physical and/or physiologic impairment.
D. Lipectomy is not considered reconstructive, and is not a covered service in the following situation
(not an all-inclusive list):
1. Performed on any site including buttocks, arms, legs, neck, abdomen and medial thigh
Suction Assisted Lipectomy of the Trunk
Suction Assisted Lipectomy of the Trunk (CPT code 15877) is not considered reconstructive (unless
part of an approved procedure), and is not a covered service.
Coverage Limitations and Exclusions
Some states require benefit coverage for services that the plan considers cosmetic procedures, such as
repair of external congenital anomalies in the absence of a functional impairment. Please refer to
enrollee’s plan specific documents.
Criteria for a Procedure to be considered Reconstructive and Medically Necessary:
1.
There is documentation that the physical abnormality and/or physiological abnormality is
causing a functional impairment (as defined in the Definitions section below) that requires
correction.
2.
The proposed treatment is of proven efficacy; and is deemed likely to significantly improve or
restore the patient’s physiological function.
Coverage Limitations and Exclusions
Some states require benefit coverage for services that the plan considers cosmetic procedures, such as
repair of external congenital anomalies in the absence of a functional impairment. Please refer to the
enrollee’s plan specific documents.
1.
Cosmetic Procedures are excluded from coverage. Procedures that correct an anatomical
Congenital Anomaly without improving or restoring physiologic function are considered
Cosmetic Procedures. The fact that a Covered Person may suffer psychological consequences or
socially avoidant behavior as a result of an Injury, Sickness or Congenital Anomaly does not
classify surgery (or other procedures done to relieve such consequences or behavior) as a
reconstructive procedure.
Cosmetic and Reconstructive Procedures
Page 9 of 42
2.
Any procedure that does not meet the reconstructive criteria above in the Indications for
Coverage section
RHINOPLASTY AND OTHER NASAL SURGERIES
Some states require benefit coverage for services that the plan considers cosmetic procedures, such as
repair of external congenital anomalies in the absence of a functional impairment. Please refer to
enrollee’s plan specific documents.
RHINOPLASTY FOR NASAL VESTIBULAR STENOSIS OR ALAR COLLAPSE:
Repair of nasal vestibular stenosis or alar collapse is considered reconstructive and medically
necessary when all of the following criteria are present:
A. Prolonged, persistent obstructed nasal breathing due to internal and/or external nasal valve
compromise (see definition below), and
B. Internal valve compromise due to collapse of the upper lateral cartilage and/or external nasal
valve compromise due to collapse of the alar (lower lateral) cartilage resulting in an anatomic
mechanical nasal airway obstruction that is a primary contributing factor for obstructed nasal
breathing and
C. Other causes have been eliminated as the primary cause of nasal obstruction (eg. sinusitis,
allergic rhinitis, vasomotor rhinitis, nasal polyposis, adenoid hypertrophy, nasopharyngeal
masses)
RHINOPLASTY FOR CONGENITAL ANOMALIES:
The following are considered reconstructive and medically necessary when the following criteria are
present:
Rhinoplasty is considered reconstructive when performed for a nasal deformity associated with
congenital craniofacial anomalies including, but not limited to Pierre Robin, Apert Syndrome, Fraser
Syndrome, Binder Syndrome, Goldenhar Syndrome, Nasal dermoids, Tessier Nasal Cleft (most
commonly #1) or associates with a cleft lip or cleft palate.
SEPTAL DERMATOPLASTY (CPT 30620):
Septal dermatoplasty is considered reconstructive when:
A. There is a documented functional impairment (eg. obstruction, pain or bleeding) due to diseased
nasal mucosa, and
B. The functional impairment will be eliminated by a skin graft.
LYSIS INTRANASAL SYNECHIA (CPT 30560):
Lysis intranasal synechia is considered reconstructive when:
A. There is a documented functional impairment (eg. obstruction, pain or bleeding) due to
intranasal synechia (adhesions/scar bands), and
B. The functional impairment will be eliminated by lysis of the synechia.
Cosmetic and Reconstructive Procedures
Page 10 of 42
Documentation:
Rhinoplasty or other nasal surgery documentation should include the evaluation and management note
for the date of service and the note for the day the decision to perform surgery was made. The
enrollee’s medical record must contain, and be available for review on request, the following
information:
• Physician office notes
• Radiologic imaging
• Photographs that document the nasal anomaly
Coverage Limitations and Exclusions
Cosmetic Procedures are excluded from coverage, including but not limited to:
A. Procedures that correct an anatomical Congenital Anomaly without improving or restoring
physiologic function are considered Cosmetic Procedures. The fact that a Covered Person may
suffer psychological consequences or socially avoidant behavior as a result of an Injury,
Sickness or Congenital Anomaly does not classify surgery (or other procedures done to relieve
such consequences or behavior) as a reconstructive procedure.
B. Rhinoplasty, unless Rhinoplasty criteria above are met
C. Any procedure that does not meet the reconstructive criteria above
D. Rhinoplasty procedures performed to improve appearance (check enrollee’s plan specific
document)
FOR COSMETIC AND/OR RECONSTRUCTIVE PROCEDURES NOT SPECIFIED ABOVE
The decision regarding whether the requested procedure will be covered as a reconstructive or excluded
from coverage as cosmetic will require review of the following clinical information/documentation, and
such other documentation as may be reasonably requested:
A. Contemporaneous physician office notes with the history of the medical condition(s)
requiring treatment or surgical intervention. This documentation must include all of the
following;
a. A well-defined physical and/or physiological abnormality resulting in a medical
condition that has required or requires treatment ; and
b. The physical and/or physiological abnormality has resulted in a functional deficit;
and
c. The functional deficit is recurrent or persistent in nature
B. Appropriate clinical studies/tests addressing the physical and/or physiological abnormality
that confirm its presence and the degree to which it is causing impairment;
C. High-quality color photographs, where applicable, documenting the physical and/or
physiological abnormality accounting for the functional impairment (as defined in the
Definition section below). The date take and the service reference identification number
(obtained at time of notification) or patient’s name and ID number must be documented on
the photograph(s).
D. Treating physician’s plan of care (proposed procedures), which must include the expected
outcome for the improvement of the functional deficit.
Cosmetic and Reconstructive Procedures
Page 11 of 42
Process and Rationale to Consider a Requested Procedure as Reconstructive:
When complete, we will be review the information supplied above to render a coverage determination.
A requested procedure will be deemed reconstructive and therefore covered when:
1. There has been documentation of a physical and/or physiological abnormality and
quantification by contemporaneous office notes, objective studies and tests, and
photographs of the physical and/or physiological abnormality
2. There is documentation that the physical abnormality and/or physiological abnormality
is causing a functional impairment (as defined in the Definition section below) that
requires correction
3. The proposed treatment is of proven efficacy; and is deemed likely to significantly
improve or restore the patient’s physiological function
MEDICARE COVERAGE RATIONALE
Medicare does not have a National Coverage Determination for Cosmetic and Reconstructive Surgery.
There is a Local Coverage Determination for Nevada for Plastic Surgery (L35163), accessed November
2015. The Local Coverage Determination is as follows:
Plastic Surgery (L35163):
According to the American Society of Plastic Surgery, the specialty of plastic surgery includes
reconstructive surgery and cosmetic 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 is performed to reshape normal structures of the body to improve the patient’s
appearance and self-esteem.
Cosmetic surgery performed purely for the purpose of enhancing one’s appearance is not eligible for
coverage. 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 not covered.
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 for individual consideration.
If a noncovered cosmetic surgery is performed in the same operative period as a covered surgical
Cosmetic and Reconstructive Procedures
Page 12 of 42
procedure, benefits will be provided for the covered surgical procedure only.
Benefits are provided for complications arising from cosmetic surgery as long as infection, hemorrhage,
or other serious documented medical complication occurs.
Payment will be made for the following procedures when performed for the reasons indicated:
1. Mammoplasty
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.
Reduction mammoplasty is performed:
1. to reduce the size of the breasts and help ameliorate symptoms caused by the hypertrophy, and
2. to reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after
cancer surgery.
3. to remove a contralateral breast that is likely to have cancer spread from the diseased breast or
to have independently developed breast cancer.
Medicare medical necessity for reduction mammoplasty is limited to circumstances in which:
1. there are signs and/or symptoms resulting from the enlarged breasts (macromastia) that have not
responded adequately to non-surgical interventions, and
2. to improve symmetry following cancer surgery on one breast.
Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit. Cosmetic
signs and/or symptoms would include ptosis, poorly fitting clothing and beneficiary perception of
unacceptable appearance.
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.
For Medicare purposes, 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 and unrelieved by:
1. Conservative analgesia,
2. Supportive measures (garment, etc.),
Cosmetic and Reconstructive Procedures
Page 13 of 42
•
•
3. Physical Therapy,
4. 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 in order 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
Medicare 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.
2. Removal of Breast Implants
For a patient who has had an implant(s) placed for reconstructive or cosmetic purposes, Medicare
considers treatment of any one or more of the following conditions 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
3. 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.
4. Suction-Assisted Lipectomy
Suction-assisted lipectomy is a surgical procedure employing high vacuum pressure to suction away
Cosmetic and Reconstructive Procedures
Page 14 of 42
localized collections of unwanted fat. When the procedure is utilized to remove a lipoma, it is
considered reconstructive surgery.
5. Dermabrasion
Coverage will be provided when correcting defects resulting from traumatic injury, surgery, burns or
disease. Dermabrasion following burn scarring is usually accomplished in 3-4 treatments. If the results
are not optimum, other treatments should be undertaken. Dermabrasion performed for postacne scarring
is classified as cosmetic and is not covered for payment.
6. Rhytidectomy
Coverage will be provided when functional impairment as a result of a disease state exists (e.g., facial
paralysis).
7. Blepharoplasty and Blepharoptosis
These procedures are addressed in a separate HCO protocol Blepharoplasty, Blepharoptosis and Brow
Ptosis Repair.
8. 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.
Cosmetic Nasal Surgery
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 noncovered under the Medicare Program.
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.
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.
Cosmetic and Reconstructive Procedures
Page 15 of 42
Services billed with a diagnosis code that is not listed in the ICD-9-CM Codes That Support Medical
Necessity section of this policy will be denied as not covered. Exceptions will be considered on a caseby-case basis.
For Medicare and Medicaid Determinations Related to States Outside of Nevada:
Please review Local Coverage Determinations that apply to other states outside of Nevada.
http://www.cms.hhs.gov/mcd/search
Important Note: Please also review local carrier Web sites in addition to the Medicare Coverage
database on the Centers for Medicare and Medicaid Services’ Website.
MEDICAID COVERAGE RATIONALE
From the Nevada Medicaid Services Manual, accessed November 2015.
Surgical procedures deemed experimental, not well established or not approved by Medicare or
Medicaid are not covered and will not be reimbursed for payment. Below is a list of definitive noncovered services.
Cosmetic Surgery: The cosmetic surgery exclusion precludes payment for any surgical procedure
directed at improving appearance. The condition giving rise to the recipient’s preoperative appearance
is generally not a consideration. The only exception to the exclusion is surgery for the prompt repair of
an accidental injury or the improvement of a malformed body member which coincidentally services
some cosmetic purpose. Examples of procedures which do not meet the exception to the exclusion are
facelift/wrinkle removal (rhytidectomy), nose hump correction, moonface, routine circumcision, etc;
Program payment may not be made for breast reconstruction for cosmetic reasons. Program payment
may be made for breast reconstruction following removal of a breast for any medical reason.
Radial keratotomy and keratoplasty to treat refractive defects are not covered. Keratoplasty that treats
specific lesions of the cornea is not considered cosmetic and may be covered.
Coverage will not be provided for botulinum toxin injections given for cosmetic or for investigational
purposes.
DEFINITIONS
Abdominoplasty: typically performed for cosmetic purposes, involves the removal of excess skin and
fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle
diastasis and a neoumbilicoplasty.
Belt Lipectomy: is a circumferential procedure which combines the elements of an abdominoplasty or
panniculectomy with removal of excess skin/fat from the lateral thighs and buttock. The procedure
involves removing a “belt” of tissue from around the circumference of the lower trunk which eliminates
Cosmetic and Reconstructive Procedures
Page 16 of 42
lower back rolls, and provides some elevation of the outer thighs, buttocks, and mons pubis. Similarly,
a circumferential lipectomy describes an abdominoplasty or panniculectomy combined with flank and
back lifts.
Benign Gynecomastia: The development of abnormally large breasts in males. It is related to the
excess growth of breast tissue (glandular), rather than excess fat tissue.
Blepharoplasty: a surgical procedure in which redundant tissue of skin, muscle or fat are excised from
the upper or lower eyelid.
Brow ptosis: a condition in which the eyebrow droops or sags.
Breast Reconstruction Steps:
Step 1 – Creation of a breast mound:
• Reposition a woman’s own muscle, fat and skin to create a breast mound.
o TRAM FLAP – the muscle, fat and skin from the lower abdomen is used to reconstruct
the breast.
o DIEP or SGAP FLAP – the fat and skin but not muscle is used from the lower abdomen
or buttocks to reconstruct the breast.
o LATISSIUMS DORSI FLAP – the muscle, fat and skin from the back are used to
reconstruct the breast – may also need a breast implant.
• Tissue expansion is used to stretch the skin to provide coverage for a breast implant to create a
breast mound.
o Requires several office visits over 4-6 months to fill the device through an internal valve
to expand the skin.
o A second surgical procedure is needed to replace the expander.
• Surgical placement of a breast implant creates a breast mound.
o May be used with a flap or alone following tissue expansion.
o Silicone and saline implants are available for reconstruction.
o Reconstruction alone may be done with an implant but usually a tissue expander is
needed.
Step 2 – Creation of a nipple and areola:
• Many different techniques are used.
• Tattooing may be used for the areola.
Breast Reduction Mammoplasty: Breast reduction includes reshaping the breast, gland resection and
reposition of the nipple-areolar complex. The procedure is usually done under general anesthesia and
may be performed in either an inpatient or outpatient setting.
Canthus: either of the corners of the eye where the upper and lower eyelids meet.
Chronic Sinusitis: Chronic rhinosinusitis (CRS) twelve (12) weeks or longer of two or more of the
following signs and symptoms:
 Mucopurulent drainage (anterior, posterior, or both)
Cosmetic and Reconstructive Procedures
Page 17 of 42



Nasal obstruction (congestion),
Facial pain-pressure-fullness, or
Decrease sense of smell and inflammation is documented by one or more of the following
findings:
o Purulent (not clear) mucus or edema in the middle meatus or ethmoid region,
o Polyps in nasal cavity or the middle meatus, and/or
o Radiographic imaging showing inflammation of the paranasal sinuses
Circumferential Lipectomy: combines an abdominoplasty with a “back lift”, both procedures being
performed together sequentially and including suction assisted lipectomy, where necessary.
Cleft Lip & Palate: birth defects that affect the upper lip and roof of the mouth. They happen when the
tissue that forms the roof of the mouth and upper lip don’t join before birth. The problem can range
from a small notch in the lip to a groove that runs into the roof of the mouth and nose.
Cosmetic Procedures:
Cosmetic Procedures are excluded from coverage. Procedures that correct an anatomical Congenital
Anomaly without improving or restoring physiologic function are considered Cosmetic Procedures. The
fact that a Covered Person may suffer psychological consequences or socially avoidant behavior as a
result of an Injury, Sickness or Congenital Anomaly does not classify surgery or other procedures done
to relieve such consequences or behavior as a reconstructive procedure. Except for reconstructive
surgery following a mastectomy, cosmetic procedures to improve appearance without restoring a bodily
function are excluded. Cosmetic procedures include:
• Surgery for sagging or extra skin,
• Any augmentation or reduction procedures,
• Rhinoplasty and associated procedures, and
• Any procedures utilizing an implant which does not alter physiologic functions unless medically
necessary.
Psychological factors (example: for self-image, difficult social or peer relations) do not constitute
restoring a physical bodily function and are not relevant to such determinations. (HPN Evidence of
Coverage, 2015)
Cosmetic Surgery: defined by the American Society of Plastic Surgeons, “is performed to reshape
normal structures of the body in order to improve the patient’s appearance and self-esteem.”
Deep Inferior Epigastric Perforator (DIEP) Flap: The DIEP flap technique uses abdominal skin and
subcutaneous tissue while sparing the rectus abdominus muscle. Blood vessels, called deep inferior
epigastric perforators (DIEP), with the overlying skin and fat supplied by them, are removed from the
lower abdomen and transferred to the chest to reconstruct a breast after mastectomy.
Ectropion: a medical condition in which the lower eyelid turns outwards.
Entropion: a medical condition in which the eyelids fold inward.
Cosmetic and Reconstructive Procedures
Page 18 of 42
Epiphora: is overflow of tears onto the face. A clinical sign or condition that constitutes insufficient
tear film drainage from the eyes in that tears will drain down the face rather than through the
nasolacrimal system.
External Nasal Valve, NARES: Lateral Crus (wing) of the lower lateral (alar) cartilage.
Frankfurt Horizontal: a horizontal plane represented in profile by a line between the lowest point on
the margin of the orbit and the highest point on the margin of the auditory measure.
Functional/Physical Impairment: A physical/functional or physiological impairment causes deviation
from the normal function of a tissue or organ. This results in a significantly limited, impaired, or
delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by
difficulties in one or more of the following areas: physical and motor tasks; independent movement;
performing basic life functions.
Gluteal Artery Perforator (GAP) Free Flap:
• Superior Gluteal Artery Perforator (S-Gap) Flap
The superior gluteal artery perforator flap involves microsurgical transfer of skin and fat from
the buttock without muscle sacrifice. The flap is vascularized by one single perforator
originating from the superior gluteal artery.
• Inferior Gluteal Artery Perforator (I-Gap) Free Flap
The IGAP is harvested using the same microsurgical, muscle-sparing techniques as the DIEP
and S-Gap flaps.
Gynecomastia: Excessive development of the male mammary glands due mainly to ductal proliferation
with periductal edema: frequently secondary to increased estrogen levels, mild gynecomastia may occur
in normal adolescence. (from Stedman’s 25th edition)
High Quality Photograph: Ideally a high-quality print should be in color have at least 200 pixels per
inch. It must be detailed enough to show the patient’s anatomy that is described in the physician’s
office notes. If submitted as a hard copy, the image must be on photographic paper.
Illness: Illness means an abnormal state of health resulting from disease, sickness or malfunction of the
body; or a congenital malformation, which causes functional impairment. For purposes of this EOC,
Illness also includes sterilization or circumcision. Illness does not include any state of mental health or
mental disorder other than Mental Illness as it is defined in this EOC. (HPN Generic Evidence of
Coverage, 2014).
Injury: means physical damage to the body inflicted by a foreign object, force, temperature, or
corrosive chemical. (HPN Generic Evidence of Coverage, 2015).
Cosmetic and Reconstructive Procedures
Page 19 of 42
Latissimus Dorsi Flap (LD): The LD flap moves muscle (and skin if required) from the back to
reconstruct the breast. It may be transferred as a free tissue transfer or rotated into place as a pedicle
flap to reconstruct the breast.
Liposuction Suction-Assisted Lipectomy: suction-assisted lipectomy (SAL), traditionally known as
liposuction, is a method of removing unwanted fatty deposits from specific areas of the face and body.
The surgeon makes a small incision and inserts a cannula attached to a vacuum device that suctions out
the fat. Areas suitable for liposuction include the chin, neck, cheeks, upper arms, area above the breasts,
the abdomen, flanks, the buttocks, hips, thighs, knees, calves and ankles. Liposuction can improve body
contour and provide a sleeker appearance. Surgeons may also use liposuction to remove lipomas
(benign fatty tumors) in some cases.
Lower Body Lift: is a procedure that treats the lower trunk and thighs as a unit by eliminating a
circumferential wedge of tissue that is generally, but not always, more inferiorly positioned laterally
and posteriorly than a belt lipectomy.
Mastectomy: Mastectomy includes partial (lumpectomy, tylectomy, quadrantectomy, and
segmentectomy), simple, and radical. A mastectomy does not include aspirations, biopsy (open or
core), excision of cysts, fibroadenomas or other benign or malignant tumors, aberrant breast tissue, duct
lesions, nipple or areolar lesions, and treatment of gynecomastia.
Mastopexy: also known as breast lift is a surgical procedure that raises and reshapes sagging breasts,
and (if desirable) reduces the size of the areola. Breast lift combined with implant surgery can enlarge
as well as firm sagging breasts.
Mini or modified abdominoplasty: is typically performed on patients with a minimal to moderate
defect as well as mild to moderate skin laxity and muscle flaccidity and do not usually involve muscle
plication above the umbilical level or neoumbilicoplasty.
Nasal Endoscopy: commonly referred to as nasopharyngoscopy, rhinolaryngoscopy,
rhinopharyngoscopy or rhinoscopy, is the use of a flexible fiberoptic endoscope to evaluate upper
airways (nasal passages, nasopharynx, oropharynx, and larynx).
Nasal Valve: External and internal components, is described anatomically as the cross-sectional area of
the nasal cavity with the greatest overall resistance to airflow, thus acting as a dominant determinant for
nasal inspiration. External valve is defined as the area in the vestibule, under the nasal ala, bounded by
the caudal septum, medial crura of the alar cartilages, alar rim and nasal sill. The internal valve is
located approximately 1.3cm from the nares and corresponds to the region under the upper lateral
cartilages, bound medially by the septum, inferiorly by the head of the inferior turbinate and laterally by
the upper lateral cartilage.
Nasal Vestibular Stenosis: is defined as a narrowing of the nasal inlet resulting in airway obstruction.
Causes include nasal trauma, infection, and iatrogenic insults.
Cosmetic and Reconstructive Procedures
Page 20 of 42
Panniculectomy: involves the removal of hanging excess skin/fat in a transverse or vertical wedge but
does not include muscle plication, neoumbilicoplasty or flap elevation. A cosmetic abdominoplasty is
sometimes performed at the time of a functional panniculectomy.
Panniculus: is a medical term describing a dense layer of fatty tissue growth, usually in the abdominal
cavity. It can be a result of morbid obesity and can be mistaken for a tumor or hernia.
Poland Syndrome: A rare, nonfamilial anomalad of unknown cause. The components of the syndrome
include absence of the pectoralis major muscle, absence or hypoplasia of the pectoralis minor muscle,
absence of costal cartilages, hypoplasia of breast and subcutaneous tissue (including the nipple
complex), and a variety of hand anomalies. The most common chest wall reconstructive procedure in
Poland’s is rotation of the latissimus dorsi muscle to reconstruct the anterior chest wall deficiency and
anterior axillary fold. Note: Poland Syndrome does not include tuberous breasts or developmental
breast asymmetry.
Ptosis of Eyelids: Drooping or sagging
Reconstructive Surgery: defined by the American Society of Plastic Surgeons, “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.”
Recurrent Acute Sinusitis: Sinusitis with symptom duration lasting longer than ten days that requires
antibiotic treatment and four or more episodes over a recent 12 month period.
Rhinitis Medicamentosa (RM) is a condition of rebound nasal congestion brought on by extended use
of topical decongestants (e.g., oxymetazoline, phenylephrine, xylometazoline, and naphazoline nasal
sprays) that work by constricting blood vessels in the lining of the nose.
Rhinoplasty: a surgical procedure that is performed to change the shape and/or size of the nose or to
correct a broad range of nasal defects.
Septal Dermatoplasty: The physician removes diseased intranasal mucosa and replaces it with a
separately reportable split thickness graft. The surgery is performed on one nasal side. A lateral
rhinotomy is made to expose the intranasal mucosa. The diseased mucosal tissue is excised from the
septum, nasal floor, and anterior aspect of the inferior turbinate. A split thickness graft is sutured to the
recipient bed, covering the exposed cartilage and submucosal surfaces. Gauze packing and splints are
placed in the grafted nasal cavity.
Septoplasty: a surgical procedure that is performed to correct nasal septum defects or deformities by
alteration, splinting, or removal of obstructing supporting structures.
Sinus Surgery (Endoscopy): a surgical procedure performed with an endoscope to correct sinus defect
or deformities; examples include may not be all inclusive (codes 31239, 31267, 31240, 31255 31256,
31276, 31287, 31288, 31290, 31291, 31292, 31293, 31294).
Cosmetic and Reconstructive Procedures
Page 21 of 42
“Stacked” DIEP Flap: This procedure allows for incorporation of more abdominal fatty tissue than
conventional TRAM procedures or unilateral DIEP flap procedures.
Superficial Inferior Epigastric Artery (SIEA) Flap: Replaces the skin and soft tissue removed at
mastectomy with skin and fatty tissue harvested from the abdomen.
Synechia: an adhesion of parts, typically the nasal side wall to the septum.
Transverse Rectus Abdominus Myocutaneous (TRAM) Flap: The surgeon takes muscle and
overlying lower abdominal tissue and moves it to the chest area. TRAM flap may be done as either a
pedicle flap or a free flap
Torsoplasty: is a series of operative procedures, usually done together to improve the contour of the
torso, usually female (though not exclusively). This series would include abdominoplasty with
liposuction of the hips/flanks and breast augmentation and/or breast lift/reduction. In men, this could
include reduction of gynecomastia by suction assisted lipectomy/ultrasound assisted lipectomy or
excision.
Visual Field: The total area where objects can be seen in the peripheral vision while the eye is focused
on a central point.
Women’s Health and Cancer Rights Act of 1998, § 713 (a): “In general – a group health plan, and a
health insurance issuer providing health insurance coverage in connection with a group health plan, that
provides medical and surgical benefits with respect to a mastectomy shall provide, in case of a
participant or beneficiary who is receiving benefits in connection with a mastectomy and who elects
breast reconstruction in connection with such mastectomy, coverage for (1) reconstruction of the breast
on which the mastectomy has been performed; (2) surgery and reconstruction of the other breast to
produce symmetrical appearance; and (3) prostheses and physical complications all stages of
mastectomy, including lymphedemas in a manner determined in consultation with the attending
physician and the patient.”
Worm’s Eye View: is a view of an object from below, as though the observer was a worm; the
opposite of a bird’s-eye view, also known as base view.
APPLICABLE CODES – COMMERCIAL
The Current Procedural Terminology (CPT®) codes and Healthcare Common Procedure Coding
System (HCPCS) codes listed in this policy are for reference purposes only. Listing of a service or
device code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the enrollee specific benefit document and
applicable laws that may require coverage for a specific service. The inclusion of a code does not imply
any right to reimbursement or guarantee claims payment. Other policies and coverage determination
guidelines may apply. This list of codes may not be all inclusive.
Cosmetic and Reconstructive Procedures
Page 22 of 42
CPT® Code
Description
Body Contouring Procedures
Excision, excessive skin and subcutaneous tissue (includes lipectomy);
abdomen, infraumbilical panniculectomy
15832
Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
15833
Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg
15834
Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip
Excision, excessive skin and subcutaneous tissue (includes lipectomy);
15835
buttock
15836
Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm
Excision, excessive skin and subcutaneous tissue (includes lipectomy);
15837
forearm or hand
Excision, excessive skin and subcutaneous tissue (includes lipectomy);
15838
submental fat pad
Excision, excessive skin and subcutaneous tissue (includes lipectomy); other
15839
area
Excision, excessive skin and subcutaneous tissue (includes lipectomy),
15847
abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial
plication) (List separately in addition to code for primary procedure)
15876
Suction assisted lipectomy; head and neck
15877
Suction assisted lipectomy; trunk
15878
Suction assisted lipectomy; upper extremity
15879
Suction assisted lipectomy; lower extremity
Breast Related Procedures including Reconstruction
15830
11920
11921
11922
11970
11971
15271
15272
15777
19300
19301
Tattooing, intradermal introduction of insoluble opaque pigments to correct
color defects of skin, including micropigmentation; 6.0 sq cm or less
Tattooing, intradermal introduction of insoluble opaque pigments to correct
color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm
Tattooing, intradermal introduction of insoluble opaque pigments to correct
color defects of skin, including micropigmentation; each additional 20.0 sq
cm, or part thereof (list separately in addition to code for primary procedure)
Replacement of tissue expander with permanent prosthesis
Removal of tissue expander(s) without insertion of prosthesis
Application of skin substitute graft to trunk, arms, legs, total wound surface
area up to 100 sq cm; first 25 sq cm or less wound surface area
Each additional 25 sq cm wound surface area, or part thereof (list separately
in addition to code for primary procedure)
Implantation of biologic implant(eg, acellular dermal matrix)for soft tissue
reinforcement (ie, breast. trunk) (list separately in addition to code for
primary procedure)
Mastectomy for gynecomastia
Mastectomy, partial (eg., lumpectomy, tylectomy, quadrantectomy,
Cosmetic and Reconstructive Procedures
Page 23 of 42
segmentectomy);
Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy,
19302
segmentectomy); with axillary lymphadenectomy
19303
Mastectomy, simple, complete
19304
Mastectomy, subcutaneous
19305
Mastectomy, radical, including pectoral muscles, axillary lymph nodes
Mastectomy, radical, including pectoral muscles, axillary and internal
19306
mammary lymph nodes (urban type operation)
Matectomy, modified radical, including axillary lymph nodes, with or without
19307
pectoralis minor muscle, but excluding pectoralis major muscle.
19316
Mastopexy
Reduction mammaplasty (covered only to achieve symmetry of the
19318
contralateral breast post mastectomy)
19324
Mammaplasty, augmentation; without prosthetic implant
19325
Mammaplasty, augmentation; with prosthetic implant
19328
Removal of intact mammary implant
19330
Removal of mammary implant material
19355
Correction of inverted nipples
19370
Open periprosthetic capsulectomy, breast
19371
Periprosthetic capsulectomy, breast
19380
Revision of reconstructed breast
19396
Preparation of moulage for custom breast implant
19499
Unlisted procedure, breast
Craniofacial Procedures
21137
21138
21139
21172
21175
21179
21180
21181
21182
Reduction forehead; contouring only
Reduction forehead; contouring and application of prosthetic material or bone
graft (includes obtaining autograft)
Reduction forehead; contouring and setback of anterior frontal sinus wall
Reconstruction superior-lateral orbital rim and lower forehead, advancement
or alteration, with or without grafts (includes obtaining autografts)
Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead,
advancement or alteration (e.g. plagiocephaly, trigonocephaly,
brachycephaly), with or without grafts (includes obtaining autografts)
Reconstruction, entire or majority of forehead and/or supraorbital rims; with
grafts (allograft or prosthetic material)
Reconstruction, entire or majority of forehead and/or supraorbital rims; with
autograft (includes obtaining grafts)
Reconstruction by contouring of benign tumor of cranial bones (e.g. fibrous
dysplasia), extracranial
Reconstruction of orbital walls, rims, forehead, nasoethmoid complex
following intra and extracranial excision of benign tumor of cranial bone (e.g.
fibrous dysplasia), with multiple autografts (includes obtaining grafts); total
area of bone grafting less than 40sq cm
Cosmetic and Reconstructive Procedures
Page 24 of 42
21183
21184
21208
21209
21230
21235
21248
21249
21255
21256
21260
21261
21263
21267
21268
21270
21275
21280
21282
21295
21296
21299
21740
21742
Reconstruction of orbital walls, rims, forehead, nasoethmoid complex
following intra and extracranial excision of benign tumor of cranial bone (e.g.
fibrous dysplasia), with multiple autografts (includes obtaining grafts); total
area of bone grafting >40sq cm and <80sq cm.
Reconstruction of orbital walls, rims, forehead, nasoethmoid complex
following intra and extracranial excision of benign tumor of cranial bone (e.g.
fibrous dysplasia), with multiple autografts (includes obtaining grafts); total
area of bone grafting >80sq cm.
Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic
implant)
Osteoplasty, facial bones; reduction
Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining
graft)
Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)
Reconstruction of mandible or maxilla, endosteal implant (e.g. blade,
cylinder); partial
Reconstruction of mandible or maxilla, endosteal implant (e.g. blade,
cylinder); complete
Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage
(includes obtaining autografts)
Reconstruction of orbit with osteotomies (extracranial) and with bone grafts
(includes obtaining autografts) (e.g., micro-ophthalmia)
Periorbital osteotomies for orbital hypertelorism, with bone grafts;
extracranial approach
Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined
intra and extracranial approach
Periorbital osteotomies for orbital hypertelorism, with bone grafts; with
forehead advancement
Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts;
extracranial approach
Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts;
combined intra and extracranial approach
Malar augmentation, prosthetic material
Secondary revision of orbitocraniofacial reconstruction
Medial canthopexy (separate procedure)
Lateral canthopexy
Reduction of masseter muscle and bone (e.g., for treatment of benign
masseteric hypertrophy); extraoral approach
Reduction of masseter muscle and bone (e.g., for treatment of benign
masseteric hypertrophy); intraoral approach
Unlisted craniofacial and maxillofacial procedure
Reconstructive repair of pectus excavatum or carinatum; open
Reconstructive repair of pectus excavatum or carinatum; minimally invasive
approach (Nuss procedure), without thoracoscopy
Cosmetic and Reconstructive Procedures
Page 25 of 42
21743
Reconstructive repair of pectus excavatum or carinatum; minimally invasive
approach (Nuss procedure), with thoracoscopy
Rhinoplasty Repair
30400
Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
Rhinoplasty, primary; complete, external parts including bony pyramid,
30410
lateral and alar cartilages, and/or elevation of nasal tip
30420
Rhinoplasty, primary; including major septal repair
30430
Rhinoplasty, secondary; minor revision (small amount of nasal tip work)
30435
Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)
30450
Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)
Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or
30460
palate, including columellar lengthening; tip only
Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or
30462
palate, including columellar lengthening; tip, septum, osteotomies
Surgical Repair of Vestibular Stenosis
Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall
30465
reconstruction)
Miscellaneous Codes
30540
Repair choanal atresia; intranasal
30545
Repair choanal atresia; transpalatine
30560
Lysis intranasal synechia
30620
Septal or other intranasal dermatoplasty (does not include obtaining graft)
Filler Material SQ Injections
11950
Subcutaneous injection of filling material (eg, collagen); 1 cc or less
11951
Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc
11952
Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc
11954
Subcutaneous injection of filling material (eg, collagen); over 10.0 cc
Q2026 Injection Radiesse 0.1ML is covered when used for treatment of facial defects due to facial
lipidatrophy in persons with human immunodeficiency virus (HIV) and treatment of vocal fold
insufficiency.
Q2028 Injection Sculptra 0.5 mg is covered when used for treatment of facial defects due to facial
lipidatrophy in persons with human immunodeficiency virus (HIV).
Other Procedures
28344
65760
65765
65767
67911
67912
67950
Reconstruction, toe(s); polydactyly
Keratomileusis
Keratophakia
Epikeratoplasty
Correction of lid retraction
Correction of lagophthalmos, with implantation of upper eyelid lid load (e.g.,
gold weight)
Canthoplasty (reconstruction of canthus)
Cosmetic and Reconstructive Procedures
Page 26 of 42
Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva,
canthus, or full thickness, may include preparation for skin graft or pedicle
67961
flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid
margin
Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva,
canthus, or full thickness, may include preparation for skin graft or pedicle
67966
flap with adjacent tissue transfer or rearrangement; over one-fourth of lid
margin
Not Medically Necessary Codes – do not improve a functional, physical or physiological
impairment
11950
Subcutaneous injection of filling material (e.g. collagen); 1 cc or less
11951
Subcutaneous injection of filling material (e.g. collagen); 1.1 to 5.0 cc
11952
Subcutaneous injection of filling material (e.g. collagen); 5.1 to 10.0 cc
11954
Subcutaneous injection of filling material (e.g. collagen); over 10 cc
Insertion of tissue expander(s) for other than breast, including subsequent
11960
expansion
15775
Punch graft for hair transplant; 1 to 15 punch grafts
15776
Punch graft for hair transplant; over 15 punch grafts
Dermabrasion; total face (e.g., for acne scarring, fine wrinkling, rhytids,
15780
general keratosis)
15781
Dermabrasion; segmental, face
15782
Dermabrasion; regional, other than face
15783
Dermabrasion; superficial, any site (e.g., tattoo removal)
15786
Abrasion; single lesion (e.g., keratosis, scar)
Abrasion; each additional 4 lesions or less(list separately in addition to code
15787
for primary procedure)
15788
Chemical peel, facial; epidermal
15789
Chemical peel, facial; dermal
15792
Chemical peel, nonfacial; epidermal
15793
Chemical peel, nonfacial; dermal
15819
Cervicoplasty
15824
Rhytidectomy; forehead
15825
Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)
15826
Rhytidectomy; glabellar frown lines
15828
Rhytidectomy; cheek, chin and neck
15829
Rhytidectomy; superficial musculoaponeurotic system (SMAS)Flap
17380
Electrolysis epilation, each 30 minutes
17999
Unlisted procedure, skin, mucous membrane and subcutaneous tissue
Biopsy of breast; percutaneous, needle core, not using imaging guidance
19100
(separate procedure)
19101
Biopsy of breast; open, incisional
Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant
19120
breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male
Cosmetic and Reconstructive Procedures
Page 27 of 42
19125
19126
21555
21556
36468
36469
69090
69300
or female, one or more lesions
Excision of breast lesion identified by preoperative placement of radiological
marker, open; single lesion
Excision of breast lesion identified by preoperative placement of radiological
marker, open; each additional lesion separately identified by a preoperative
radiological marker (list separately in addition to code for primary procedure)
Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than
3 cm
Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg,
intramuscular); less than 5 cm
Single or multiple injections of sclerosing solutions, spider veins
(telangiectasia); limb or trunk
Single or multiple injections of sclerosing solutions, spider veins
(telangiectasia); face
Ear piercing
Otoplasty, protruding ear, with or without size reduction
CPT® is a registered trademark of the American Medical Association.
HCPCS Code
L8600
S2066
S2067
S2068
Description
Implantable breast prosthesis, silicone or equal
Breast reconstruction with gluteal artery perforator (gap) flap, including
harvesting of the flap, microvascular transfer, closure of donor site and
shaping the flap into a breast, unilateral
Breast reconstruction of a single breast with “stacked” deep inferior epigastric
perforator (DIEP) flap(s) and/or gluteal artery perforator (gap) flap(s),
including harvesting of the flap(s), microvascular transfer, closure of donor
site(s) and shaping flap into a breast, unilateral
Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or
superficial inferior epigastric artery (SIEA) flap, including harvesting of the
flap, microvascular transfer, closure of donor site and shaping the flap into a
breast, unilateral
APPLICABLE CODES – MEDICARE
See following ICD-9 codes that are appropriate for CPT codes
CPT® Codes
15570
15731
15732
15734
15736
15738
Description
Formation of direct or tubed pedicle, with or without transfer; trunk
Forehead flap with preservation of vascular pedicle (eg, axial pattern flap,
paramedian forehead flap)
Muscle, myocutaneous, or fasciocutaneous flap; head and neck (eg,
temporalis, masseter muscle, sternocleidomastoid, levator scapulae)
Muscle, myocutaneous, or fasciocutaneous flap; trunk
Muscle, myocutaneous, or fasciocutaneous flap; upper extremity
Muscle, myocutaneous, or fasciocutaneous flap; lower extremity
Cosmetic and Reconstructive Procedures
Page 28 of 42
CPT® Codes
15740
15756
15780
15781
15782
15783
15830
15832
15833
15834
15835
15836
15837
15838
15839
15847
15876
15877
15878
15879
19316
19318
19324
19325
19328
19330
19340
19342
19350
19355
Description
Flap; island pedicle requiring identification and dissection of an anatomically
named axial vessel
Free muscle or myocutaneous flap with microvascular anastomosis
Dermabrasion; total face (e.g., for acne scarring, fine wrinkling, rhytids,
general keratosis)
Dermabrasion; segmental, face
Dermabrasion; regional other than face
Dermabrasion; superficial, any site (e.g., tattoo removal)
Excision, excessive skin and subcutaneous tissue (includes lipectomy);
abdomen, infraumbilical panniculectomy
Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg
Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip
Excision, excessive skin and subcutaneous tissue (includes lipectomy);
buttock
Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm
Excision, excessive skin and subcutaneous tissue (includes lipectomy);
forearm or hand
Excision, excessive skin and subcutaneous tissue (includes lipectomy);
submental fat pad
Excision, excessive skin and subcutaneous tissue (includes lipectomy); other
area
Excision, excessive skin and subcutaneous tissue (includes lipectomy);
abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial
plication)
(list separately in addition to code for primary procedure)
Suction assisted lipectomy; head and neck
Suction assisted lipectomy; trunk
Suction assisted lipectomy; upper extremity
Suction assisted lipectomy; lower extremity
Mastopexy
Reduction mammaplasty
Mammaplasty, augmentation; without prosthetic implant
Mammaplasty, augmentation; with prosthetic implant
Removal of intact mammary implant
Removal of mammary implant material
Immediate insertion of breast prosthesis following mastopexy, mastectomy or
in reconstruction
Delayed insertion of breast prosthesis following mastopexy, mastectomy or in
reconstruction
Nipple/areola reconstruction
Correction of inverted nipples
Cosmetic and Reconstructive Procedures
Page 29 of 42
CPT® Codes
19357
19361
19364
19366
19367
19368
19369
19370
19371
19380
19396
30400
30410
30420
30430
30435
30450
Description
Breast reconstruction, immediate or delayed, with tissue expander, including
subsequent expansion
Breast reconstruction with latissimus dorsi flap, without prosthetic implant
Breast reconstruction with free flap
Breast reconstruction with other technique
Breast reconstruction with transverse rectus abdominis myocutaneous flap
(TRAM), single pedicle, including closure of donor site
Breast reconstruction with transverse rectus abdominis myocutaneous flap
(TRAM), single pedicle, including closure of donor site, with microvascular
anastomosis (supercharging)
Breast reconstruction with transverse rectus abdominis myocutaneous flap
(TRAM), double pedicle, including closure of donor site
Open periprosthetic capsulotomy, breast
Periprosthetic capsulotomy, breast
Revision of reconstructed breast
Preparation of moulage for custom breast implant
Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
Rhinoplasty, primary; complete external parts including bony pyramid, lateral
and alar cartilages, and/or elevation of nasal tip
Rhinoplasty, primary; including major septal repair
Rhinoplasty, secondary; minor revision (small amount of nasal tip work)
Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)
Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)
ICD-9 Codes that Support Medical Necessity (ICD-9 codes are no longer accepted after October
1, 2015)
The following is a list of suggested ICD-9-CM® Codes for specific CPT® code procedures. It is not an
all inclusive list for all of the conditions addressed in this policy. Providers are to use the ICD-9-CM®
Code that correctly describes the condition for which any procedure is performed.
These are the only covered ICD-9-CM codes that support MEDICARE medical necessity:
Group 1
Dermabrasion (CPT® Codes 15780-15783)
ICD-9 Codes that
Support
Description
MEDICARE Medical
Necessity
695.3
Rosacea
Full-thickness skin loss due to burn (third degree nos) of unspecified site of
941.30 – 941.59
face and head – Deep necrosis of underlying tissues due to burn (deep third
degree) of multiple sites (except eye) of face, head and neck with loss of a
Cosmetic and Reconstructive Procedures
Page 30 of 42
942.30 – 942.35
942.39
942.40 – 942.45
942.49
942.50 – 942.55
942.59
943.30 – 943.36
943.39
943.40 – 943.46
943.49
943.50 – 943.56
943.59
944.30 – 944.58
945.30 – 945.36
945.39
945.40 – 945.46
body part
Full-thickness skin loss due to burn (third degree nos) of unspecified site of
trunk – Full-thickness skin loss due to burn (third degree nos) of genitalia
Full-thickness skin loss due to burn (third degree nos) of other and multiple
sites of trunk
Deep necrosis of underlying tissues due to burn (deep third degree) of trunk
unspecified site without loss of body part – Deep necrosis of underlying
tissues due to burn (deep third degree) of genitalia without loss of genitalia
Deep necrosis of underlying tissues due to burn (deep third degree) of other
and multiple sites of trunk without loss of body part
Deep necrosis of underlying tissues due to burn (deep third degree) of
unspecified site of trunk with loss of body part – Deep necrosis of underlying
tissues due to burn (deep third degree) of genitalia with loss of genitalia
Deep necrosis of underlying tissues due to burn (deep third degree) of other
and multiple sites of trunk with loss of a body part
Full-thickness skin loss due to burn (third degree nos) of unspecified site of
upper limb – Full-thickness skin loss due to burn (third degree nos) of
scapular region
Full-thickness skin loss due to burn (third degree nos) of multiple sites of
upper limb except wrist and hand
Deep necrosis of underlying tissues due to burn (deep third degree) of
unspecified site of upper limb without loss of a body part – Deep necrosis of
underlying tissues due to burn (deep third degree) of scapular region without
loss of scapula
Deep necrosis of underlying tissues due to burn (deep third degree) of
multiple sites of upper limb except wrist and hand without loss of upper limb
Deep necrosis of underlying tissues due to burn (deep third degree) of
unspecified site of upper limb with loss of a body part – Deep necrosis of
underlying tissues due to burn (deep third degree) of scapular region with loss
of scapula
Deep necrosis of underlying tissues due to burn (deep third degree) of
multiple sites of upper limb except wrist and hand with loss of upper limb
Full-thickness skin loss due to burn (third degree nos) of unspecified site of
hand – Deep necrosis of underlying tissues due to burn (deep third degree) of
multiple sites of wrist(s) and hand(s) with loss of a body part
Full-thickness skin loss due to burn (third degree nos) of unspecified site of
lower limb – Full-thickness skin loss due to burn (third degree nos) of thigh
(any part)
Full-thickness skin loss due to burn (third degree nos) of multiple sites of
lower limb(s)
Deep necrosis of underlying tissues due to burn (deep third degree) of
unspecified site of lower limb (leg) without loss of a body part – Deep
necrosis of underlying tissues due to burn (deep third degree) of thigh (any
part) without loss of thigh
Cosmetic and Reconstructive Procedures
Page 31 of 42
945.49
945.50 – 945.56
945.59
946.3
946.4
946.5
Deep necrosis of underlying tissues due to burn (deep third degree) of
multiple sites of lower limb(s) without loss of a body part
Deep necrosis of underlying tissues due to burn (deep third degree) of
unspecified site lower limb (leg) with loss of a body part – Deep necrosis of
underlying tissues due to burn (deep third degree) of thigh (any part) with loss
of thigh
Deep necrosis of underlying tissues due to burn (deep third degree) of
multiple sites of lower limb(s) with loss of a body part
Full-thickness skin loss due to burn (third degree nos) of multiple specified
sites
Deep necrosis of underlying tissues due to burn (deep third degree) of
multiple specified sites without loss of a body part
Deep necrosis of underlying tissues due to burn (deep third degree) of
multiple specified sites with loss of a body part
Group 2 Abdominal Lipectomy/Panniculectomy
(CPT® Codes 15830, 15832, 15833, 15834, 15835, 15836, 15837 and 15847)
ICD-9 Codes that
Support
MEDICARE Medical
Necessity
031.1
035
039.0
040.0
041.00
041.01
041.02
041.03
041.04
041.05
041.09
041.10
041.11
Description
Cutaneous diseases due to other mycobacteria
Erysipelas
Cutaneous actinomycotic infection
Gas gangrene
Streptococcus infection in conditions classified elsewhere and of unspecified
site streptococcus
Streptococcus infection in conditions classified elsewhere and of unspecified
site streptococcus Group A
Streptococcus infection in conditions classified elsewhere and of unspecified
site streptococcus Group B
Streptococcus infection in conditions classified elsewhere and of unspecified
site streptococcus Group C
Streptococcus infection in conditions classified elsewhere and of unspecified
site streptococcus Group D (enterococcus)
Streptococcus infection in conditions classified elsewhere and of unspecified
site streptococcus Group G
Streptococcus infection in conditions classified elsewhere and of unspecified
site other streptococcus
Staphylococcus infection in conditions classified elsewhere and of
unspecified site staphylococcus unspecified
Methicillin susceptible staphylococcus aureus in conditions classified
elsewhere and of unspecified site
Cosmetic and Reconstructive Procedures
Page 32 of 42
ICD-9 Codes that
Support
Description
MEDICARE Medical
Necessity
Methicillin resistant staphylococcus aureus in conditions classified elsewhere
041.12
and of unspecified site
Staphylococcus infection in conditions classified elsewhere and of
041.19
unspecified site other staphylococcus
Pneumococcus infection in conditions classified elsewhere and of unspecified
041.2
site
041.3
Klebsiella pneumoniae
Escherichia coli (e. coli) infection in conditions classified elsewhere and of
041.4
unspecified site
Hemophilus influenzae (h. influenzae) infection in conditions classified
041.5
elsewhere and of unspecified site
Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and
041.6
of unspecified site
Pseudomonas infection in conditions classified elsewhere and of unspecified
041.7
site
Other specified bacterial infections in conditions classified elsewhere and of
041.81
unspecified site mycoplasma
Other specified bacterial infections in conditions classified elsewhere and of
041.82
unspecified site bacteroides fragilis
Other specified bacterial infections in conditions classified elsewhere and of
041.83
unspecified site clostridium perfringens
Other specified bacterial infections in conditions classified elsewhere and of
041.84
unspecified site other anaerobes
Other specified bacterial infections in conditions classified elsewhere and of
041.85
unspecified site other gram-negative organisms
041.86
Helicobacter pylori [h. pylori]
Other specified bacterial infections in conditions classified elsewhere and of
041.89
unspecified site other specified bacteria
Bacterial infection unspecified in conditions classified elsewhere and of
041.9
unspecified site
110.3
Dermatophytosis of groin and perianal area
110.8
Dermatophytosis of other specified sites
110.9
Dermatophytosis of unspecified site
112.2
Candidiasis of other urogenital sites
112.3
Candidiasis of skin and nails
112.9
Candidiasis of unspecified site
707.00
Pressure ulcer, unspecified site
707.10
Unspecified ulcer of lower limb
707.11
Ulcer of thigh
707.8
Chronic ulcer of other specified sites
Cosmetic and Reconstructive Procedures
Page 33 of 42
ICD-9 Codes that
Support
Description
MEDICARE Medical
Necessity
707.9
Chronic ulcer of unspecified site
729.39
Panniculitis affecting other sites
Group 3
Reconstructive Breast Surgery
(CPT® Codes 19316, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364,
19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396)
ICD-9 Codes that
Support
MEDICARE Medical
Necessity
174.0
174.1
174.2
174.3
174.4
174.5
174.6
174.8
174.9
175.0
175.9
198.2
198.81
217
232.5
233.0
238.3
239.3
612.1
996.54
V10.3
V43.82
V45.71
V51.0
V52.4
V58.42
Description
Malignant neoplasm of nipple and areola of female breast
Malignant neoplasm of central portion of female breast
Malignant neoplasm of upper-inner quadrant of female breast
Malignant neoplasm of lower-inner quadrant of female breast
Malignant neoplasm of upper-outer quadrant of female breast
Malignant neoplasm of lower-outer quadrant of female breast
Malignant neoplasm of axillary tail of female breast
Malignant neoplasm of other specified sites of female breast
Malignant neoplasm of breast (female) unspecified site
Malignant neoplasm of nipple and areola of male breast
Malignant neoplasm of other and unspecified sites of male breast
Secondary malignant neoplasm of skin
Secondary malignant neoplasm of breast
Benign neoplasm of breast
Carcinoma in situ of skin of trunk except scrotum
Carcinoma in situ of breast
Neoplasm of uncertain behavior of breast
Neoplasm of unspecified nature of breast
Disproportion of reconstructed breast
Mechanical complication of breast prosthesis
Personal history of malignant neoplasm of breast
Breast replacement status
Acquired absence of breast and nipple
Encounter for breast reconstruction following mastectomy
Fitting and adjustment of breast prosthesis and implant
Aftercare following surgery for neoplasm
Cosmetic and Reconstructive Procedures
Page 34 of 42
Reduction Mammoplasty (CPT® Code 19318)
Two diagnoses are required for payment (One primary and one secondary).
PRIMARY
ICD-9 Codes that
Support
Description
MEDICARE Medical
Necessity
611.1*
Hypertrophy of breast
612.1*
Disproportion of reconstructed breast
*Primary diagnosis 611.1 or 612.1 must be billed with one of the following secondary diagnoses:
695.89, 719.41, 723.1, 724.1, 724.5, 782.1 (Two diagnoses are required for payment.)
SECONDARY
ICD-9 Codes that
Support
MEDICARE Medical Description
Necessity
(One of the following
diagnoses*)
695.89*
Other specified erythematous conditions
719.41*
Pain in joint involving shoulder region
723.1*
Cervicalgia
724.1*
Pain in thoracic spine
724.5*
Backache unspecified
782.1*
Rash and other nonspecific skin eruption
*Secondary diagnoses 695.89, 719.41, 723.1, 724.1, 724.5, 782.1 must be
billed with the following primary diagnosis: 611.1 or 612.1
(Two diagnoses are required for payment.)
Group 5
Rhinoplasty (CPT® Codes 30400-30450)
ICD-9 Codes that
Support
MEDICARE Medical
Necessity
160.0
170.0
172.3
173.3
195.0
212.0
213.0
216.3
Description
Malignant neoplasm of nasal cavities
Malignant neoplasm of bones of skull and face except mandible
Malignant melanoma of skin of other and unspecified parts of face
Other malignant neoplasm of skin of other and unspecified parts of face
Malignant neoplasm of head, face and neck
Benign neoplasm of nasal cavities middle ear and accessory sinuses
Benign neoplasm of bones of skull and face
Benign neoplasm of skin of other and unspecified parts of face
Cosmetic and Reconstructive Procedures
Page 35 of 42
232.3
478.19
802.0
802.1
Carcinoma in situ of skin of other and unspecified parts of face
Other disease of nasal cavity and sinuses
Closed fracture of nasal bones
Open fracture of nasal bones
ICD-10 Codes (Effective 10/01/15)
ICD-10-CM (diagnoses) and ICD-10-PCS (inpatient procedures) must be used to report services
provided on or after October 1, 2015.
ICD-10 codes will not be accepted for services provided prior to October 1, 2015.
ICD-10
Diagnosis
Codes
(Effective
10/01/15)
Description
C50.011
Malignant neoplasm of nipple and areola, right female breast
C50.012
Malignant neoplasm of nipple and areola, left female breast
C50.019
Malignant neoplasm of nipple and areola, unspecified female breast
C50.021
Malignant neoplasm of nipple and areola, right male breast
C50.022
Malignant neoplasm of nipple and areola, left male breast
C50.029
Malignant neoplasm of nipple and areola, unspecified male breast
C50.111
Malignant neoplasm of central portion of right female breast
C50.112
Malignant neoplasm of central portion of left female breast
C50.119
Malignant neoplasm of central portion of unspecified female breast
C50.121
Malignant neoplasm of central portion of right male breast
C50.122
Malignant neoplasm of central portion of left male breast
C50.129
Malignant neoplasm of central portion of unspecified male breast
C50.211
Malignant neoplasm of upper-inner quadrant of right female breast
C50.212
Malignant neoplasm of upper-inner quadrant of left female breast
C50.219
Malignant neoplasm of upper-inner quadrant of unspecified female
breast
C50.221
Malignant neoplasm of upper-inner quadrant of right male breast
C50.222
Malignant neoplasm of upper-inner quadrant of left male breast
C50.229
Malignant neoplasm of upper-inner quadrant of unspecified male
breast
Cosmetic and Reconstructive Procedures
Page 36 of 42
C50.311
Malignant neoplasm of lower-inner quadrant of right female breast
C50.312
Malignant neoplasm of lower-inner quadrant of left female breast
C50.319
Malignant neoplasm of lower-inner quadrant of unspecified female
breast
C50.321
Malignant neoplasm of lower-inner quadrant of right male breast
C50.322
Malignant neoplasm of lower-inner quadrant of left male breast
C50.329
Malignant neoplasm of lower-inner quadrant of unspecified male
breast
C50.411
Malignant neoplasm of upper-outer quadrant of right female breast
C50.412
Malignant neoplasm of upper-outer quadrant of left female breast
C50.419
Malignant neoplasm of upper-outer quadrant of unspecified female
breast
C50.421
Malignant neoplasm of upper-outer quadrant of right male breast
C50.422
Malignant neoplasm of upper-outer quadrant of left male breast
C50.429
Malignant neoplasm of upper-outer quadrant of unspecified male
breast
C50.511
Malignant neoplasm of lower-outer quadrant of right female breast
C50.512
Malignant neoplasm of lower-outer quadrant of left female breast
C50.519
Malignant neoplasm of lower-outer quadrant of unspecified female
breast
C50.521
Malignant neoplasm of lower-outer quadrant of right male breast
C50.522
Malignant neoplasm of lower-outer quadrant of left male breast
C50.529
Malignant neoplasm of lower-outer quadrant of unspecified male
breast
C50.611
Malignant neoplasm of axillary tail of right female breast
C50.612
Malignant neoplasm of axillary tail of left female breast
C50.619
Malignant neoplasm of axillary tail of unspecified female breast
C50.621
Malignant neoplasm of axillary tail of right male breast
C50.622
Malignant neoplasm of axillary tail of left male breast
C50.629
Malignant neoplasm of axillary tail of unspecified male breast
C50.811
Malignant neoplasm of overlapping sites of right female breast
Cosmetic and Reconstructive Procedures.doc
Page 37 of 42
ICD-10
Diagnosis Codes
(Effective
10/01/15)
Description
C50.812
Malignant neoplasm of overlapping sites of left female breast
C50.819
Malignant neoplasm of overlapping sites of unspecified female
breast
C50.821
Malignant neoplasm of overlapping sites of right male breast
C50.822
Malignant neoplasm of overlapping sites of left male breast
C50.829
Malignant neoplasm of overlapping sites of unspecified male breast
C50.911
Malignant neoplasm of unspecified site of right female breast
C50.912
Malignant neoplasm of unspecified site of left female breast
C50.919
Malignant neoplasm of unspecified site of unspecified female breast
C50.921
Malignant neoplasm of unspecified site of right male breast
C50.922
Malignant neoplasm of unspecified site of left male breast
C50.929
Malignant neoplasm of unspecified site of unspecified male breast
C79.81
Secondary malignant neoplasm of breast
D05.00
Lobular carcinoma in situ of unspecified breast
D05.01
Lobular carcinoma in situ of right breast
D05.02
Lobular carcinoma in situ of left breast
D05.10
Intraductal carcinoma in situ of unspecified breast
D05.11
Intraductal carcinoma in situ of right breast
D05.12
Intraductal carcinoma in situ of left breast
D05.80
Other specified type of carcinoma in situ of unspecified breast
D05.81
Other specified type of carcinoma in situ of right breast
D05.82
Other specified type of carcinoma in situ of left breast
D05.90
Unspecified type of carcinoma in situ of unspecified breast
D05.91
Unspecified type of carcinoma in situ of right breast
D05.92
Unspecified type of carcinoma in situ of left breast
Z42.1
Encounter for breast reconstruction following mastectomy
Cosmetic and Reconstructive Procedures.doc
Page 38 of 42
Z85.3
Personal history of malignant neoplasm of breast
Z90.10
Acquired absence of unspecified breast and nipple
Z90.11
Acquired absence of right breast and nipple
Z90.12
Acquired absence of left breast and nipple
Z90.13
Acquired absence of bilateral breasts and nipples
REFERENCES
Ali O, Donohue PA. Gynecomastia. In: Kliegman RM, Stanton BF, Geme JW, Schor NF, Behrman
RE, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 579.
American Medical Association. Current Procedural Terminology: CPT Professional Edition.
American Medical Association (AMA). CPT® Assistant Online. 2014. Available at: http://www.amaassn.org/ama.
American Journal of Otolaryngology, Vol 23, No 2 (March-April): 2002: pp 85-90.
American Society of Plastic Surgeons (ASPS) available at: http://www.plasticsurgery.org/. Accessed
January 2016.
American Society of Plastic Surgeons. Breast Reconstruction Procedures Steps. Available at:
http://www.plasticsurgery.org. Accessed January 2016
American Society of Plastic Surgeons (ASPS). Practice Parameter. Treatment Principles of Silicone
Breast Implants. March 2005.
Ansstas, G, Ansstas, M, Griffing, G, Gynecomastia. Medscape.
http://emedicine.medscape.com/article/120858-overview. Accessed January 2016.
Asaria J, Pepper JP, Baker SR. Key issues in nasal reconstruction. Current Opinion in Otolaryngology
and Head and Neck Surgery 2010;18(4):278-82. DOI: 10.1097/MOO.0b013e32833af8f8
Batra PS, Kanowitz SJ, Citardi MJ. Clinical utility of intraoperative volume computed tomography
scanner for endoscopic sinonasal and skull base procedures. Am J Rhinol. 2008; 22(5):511-515.
Benninger M, Farrar JR, Blaiss M, et al. Evaluating approved medications to treat allergic rhinitis in
the United States: an evidence-based review of efficacy for nasal symptoms by class. Ann Allergy
Asthma Immunol. 2010; 104(1):13-29.
Benjamin Y. Huang, M. et.al., Failed Endoscopic Sinus Surgery: Spectrum of CT Findings in the
Frontal Recess1
Cosmetic and Reconstructive Procedures.doc
Page 39 of 42
Centers for Medicare and Medicaid. Novitas LCD COSMETIC and Reconstructive Surgery (L32763).
Accessed October 2015.
Coleman, W. Dermatologic therapy: New directions in surgical therapy. Dermatol Clin.
1998(Apr.);16(2): 253-259.
Eavey, R. Ear malformations: what a pediatrician can do to assist with auricular reconstruction. Ped
Clin North Am. 1996(Dec.);43(6): 1233-1244.
Esteitie R, deTineo M, Naclerio RM, Baroody FM. Effect of the addition of montelukast to fluticasone
propionate for the treatment of perennial allergic rhinitis. Ann Allergy Asthma Immunol. 2010;
105:155-161.
Fawaz SA, Ezzat WF, Salman MI. Sensitivity and specificity of computed tomography and magnetic
resonance imaging in the diagnosis of isolated sphenoid sinus diseases. Laryngoscope. 2011;
121(7):1584-1589.
Fortune, D., and Ries, W. Options in the management of the aging face: an otolaryngology-facial
plastic and reconstructive surgeon's perspective. Med Clin North Am. 1999(Jan.);83(1): 283-301.
Goiato MC, Dos Santos DM, Fajardo RS, de Carvalho Dekon SF. Solutions for nasal defects. Journal
of Craniofacial Surgery 2009;20(6):2238-41. DOI: 10.1097/SCS.0b013e3181bf858c
Hoag JB, Terry P, Mitchell S, et al. An epistaxis severity score for hereditary hemorrhagic
telangiectasia. Laryngoscope. 2010; 120(4):838-843.
International Forum Allergy and Rhinology. Volume 3. January 2013.
Matarasso, A. Analysis and treatment of the aging face: facialplasty. Dermatol Clin. 1997a
(Oct.);15(4): 649-658.
Matarasso, S., Hanke, C., and Alster, T. Analysis and treatment of the aging face: cutaneous
resurfacing. Dermatol Clin. 1997b (Oct.);15(4): 569-582.
Mayo Clinic: Diseases and Conditions. Gynecomastia (enlarged breasts in men).
http://www.mayoclinic.com/health/gynecomastia/DS00850. Accessed January 2016.
MCG Care Guidelines, Ambulatory Care 17th Edition, 2013. Septoplasty: ACG: A-0182 (AC).
MCG™ Care Guidelines, 19th edition, 2015. Panniculectom:y ACG: A-0498 (AC)
MCG Care Guidelines, Ambulatory Care 19th Edition, 2015. Rhinoplasty: ACG: A-0184 (AC).
Moon IJ, Kim SW, Han DH, et al. Mucosal cysts in the paranasal sinuses: long-term follow-up and
clinical implications. Am J Rhinol Allergy. 2011; 25(2):98-102.
Cosmetic and Reconstructive Procedures.doc
Page 40 of 42
Nevada Dept. of Health & Human Services-Division of HealthCare Financing and Policy (DHCFP)
Medicaid Services Manual. Accessed October 2015
NIH Medline Plus http://www.nlm.nih.gov/medlineplus/ency/article/003165.htm
Narula HS, Carlson HE. Gynecomastia. Endocrinol Metab Clin North Am. 2007/36:497-519.
Otolaryngology, Head and Neck Surgery (2007) 137, S1-S31: Clinical Practice Guideline: Adult
Sinusitis.
Peters AT, Spector S, Hsu J, et al. Diagnosis and Management of Rhinosinusitis: A Practice Parameter
Update, 2014-a0-01Z, Volume 113, Issue 4, Pages 347-385, Copyright 2014 American College of
Allergy, Asthma & Immunology.
Poetker DM, Reh DD. A comprehensive review of the adverse effects of systemic corticosteroids.
Otolaryngol Clin N Am. 2010; 43:753-768.
Ratner PH, Hampel F, Van Bavel J, et al. Combination therapy with azelastine hydrochloride nasal
spray and fluticasone propionate nasal spray in the treatment of patients with seasonal allergic rhinitis.
Ann Allergy Asthma Immunol. 2008; 100(1): 74-81.
Rodrigo GJ, Yañez A. The role of antileukotriene therapy in seasonal allergic rhinitis: a systematic
review of randomized trials. Ann Allergy Asthma Immunol. 2006; 96(6):779-786.
Targeting Skull Base Disorders, multidisciplinary program tackles challenging conditions in a complex
region. University Hospitals, Case Medical Center, Case Western Reserve University Winter 2013
Sabiston. Aesthetic Surgery. In Textbook of Surgery, 15th ed. 1997. W.B. Saunders Company.
Smith TL, Kern RC, Palmer JN, et al. Medical therapy vs surgery for chronic rhinosinusitis: a
prospective, multi-institutional study. Int Forum Allergy Rhinol. 2011; 1:235-241.
Smith TL, Litvack JR, Hwang PH, et al. Determinants of outcomes of sinus surgery: a multiinstitutional prospective cohort study. Otolaryngol Head Neck Surg. 2010; 142:55-63.
Snidvongs K, Kalish L, Sacks R, et al. Topical steroid for chronic rhinosinusitis without polyps.
Cochrane Database Syst Rev. 2011; 8:CD009274.
Cosmetic and Reconstructive Procedures.doc
Page 41 of 42
PROTOCOL HISTORY/REVISION INFORMATION
Date
01/27/2016
12/23/2015
11/19/2015
10/29/2015
07/23/2015
06/25/2015
04/23/2015
2014 X 4
2013 X 5
2012 X 4
2011 X 3
2010 X 3
03/20/2009
Action/Description
Corporate Medical Affairs Committee
The foregoing Health Plan of Nevada/Sierra Health & Life Healthcare Operations protocol has been
adopted from an existing UnitedHealthcare coverage determination guideline that was researched,
developed and approved by the UnitedHealthcare Coverage Determination Committee.
Cosmetic and Reconstructive Procedures.doc
Page 42 of 42