Introduction
There are generally two types of plastic surgery, cosmetic and reconstructive. Cosmetic surgery is performed to improve appearance, not to improve function or ability. The plan does not cover cosmetic surgery. Reconstructive surgery focuses on reconstructing defects of the body or face due to trauma, burns, disease, or birth disorders. Reconstructive surgery is designed to restore or improve function associated with the presence of a defect. This policy outlines when reconstructive surgery may be covered.
Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered.
Policy Coverage Criteria
Procedure Cosmetic
Cosmetic services A procedure is considered cosmetic when the medical necessity criteria in this policy are not met.
A procedure or drug may be considered cosmetic when the primary purpose is to preserve or improve appearance in the absence of a physical functional impairment (defined below).
Procedures
• Procedures that are usually considered cosmetic include but are not limited to the following:
o Abdominoplasty (includes mini or modified abdominoplasty)
o Arm lift (brachioplasty)
o Body or ear piercing
o Breast augmentation (breast implants)
o Breast lift (mastopexy)
o Buttock or thigh lift
o Chin implant (genioplasty)
o Dermabrasion
o Diastasis recti repair
o Electrolysis or laser hair removal
o Excessive/redundant skin removal from limbs and other
areas of the body
o Fat grafts
o Injectable dermal fillers used to sculpt body contours
o Inverted nipple correction
o Labial reduction (labiaplasty)/(aesthetic alteration of the female genitalia)
o Lipectomy (includes belt lipectomy, circumferential lipectomy and others)
o Lower body lift
o Neck tucks
o Penis enhancement surgery
Procedure Cosmetic
o Otoplasty for large or protruding ears
o Removal of frown lines
o Rhytidectomy (face lift)
o Tattoo (also see reconstructive services section)
o Tattoo removal
o Torsoplasty
o Treatment for skin wrinkles
o Treatment for spider veins (telangiectasia)
Pharmaceutical Agents
• Treatment with the following pharmaceutical agents is usually considered cosmetic (not an all- inclusive list):
o Botox Cosmetic® or Juvéderm® (onabotulinum toxin for cosmetic use)
o Egrifta® (tesamorelin)
o Juvederm
o Kybella™ (deoxycholic acid) injection
o Latisse® (bimatoprost)
o Mirvaso® (brimonidine topical gel)
o Promiseb® (multiple ingredients)
o Vaniqa® (eflornithine)
o Rhofade® (oxymetazoline hydrochloride) topical cream
o Any topical agent not containing an FDA-approved legend drug whose primary purpose is other than to preserve or improve appearance in the absence of a physical functional impairment
Procedure Reconstructive / Medical Necessity
Reconstructive services A procedure is considered reconstructive when the primary purpose is to improve or restore function of a physical functional impairment of an abnormal body structure.
The following procedures may be considered medically necessary when criteria are met (see Related Policies):
• Blepharoplasty
• Breast reduction
• Gynecomastia surgery
Procedure Reconstructive / Medical Necessity
• Orthognathic surgery
• Panniculectomy
• Rhinoplasty
• Scar revision when functional impairment symptoms are present
• Skin tag removal when causing irritation and bleeding
• Tattoo when done as part of breast reconstructive surgery after mastectomy
Breast cancer The Women’s Health and Cancer Rights Act of 1998 requires that in patients with breast cancer or a history of breast cancer, all stages of reconstruction of the breast on which a mastectomy was performed, surgery and reconstruction of the other breast to produce symmetrical appearance, prostheses and treatment of physical complications of the mastectomy including lymphedema are considered medically necessary.
Coding
Code Description
Medically Necessary Services
CPT
17106 Destruction of cutaneous vascular proliferative lesions (eg, laser technique; less than 10 sq cm
17107 Destruction of cutaneous vascular proliferative lesions (eg, laser technique; 10.0 to 50.0 sq cm
17108 Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm
21125 Augmentation, mandibular body or angle; prosthetic material
21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft)
21137 Reduction forehead; contouring only
21138 Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft)
Code Description
Medically Necessary Services
CPT
21139 Reduction forehead; contouring and setback of anterior frontal sinus wall
65760 Keratomileusis
65765 Keratophakia
65767 Epikeratoplasty
Code Description
Cosmetic Services
CPT
11920 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less
11921 Tattooing, intradermal introduction of insoluable opaque pigments to correct color defects of skin, including micropigmentation; 6.1 sq cm to 20.0 sq cm
11922 Tattooing, intradermal introduction of insoluable 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)
11950 Subcutaneous injection of filling material (eg, collagen); 1cc 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
11960 Insertion of tissue expander(s) for other than breast, including subsequent expansion
15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)
15781 Dermabrasion; segmental, face
15782 Dermabrasion; regional, other than face
15783 Dermabrasion; superficial, any site, (eg, tattoo removal)
15786 Abrasion; single lesion (eg keratosis, scar)
15787 Abrasion; each additional four lesions or less (List separately in addition to code for primary procedure)
15819 Cervicoplasty
Code Description
Cosmetic Services
15824 Rhytidectomy; forehead
15825 Rhytidectomy; neck with platysmal tightening (platsymal flap, P-flap)
15826 Rhytidectomy; glabellar frown lines
15828 Rhytidectomy; cheek, chin, and neck
15829 Rhytidectomy; superficial musculoapneurotic system SMAS flap
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
15835 Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock
15836 Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm
15837 Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand
15838 Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad
15839 Excision Excessive Skin and subcutaneous tissue (includes lipectomy); other areas
15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, 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
19355 Correction of inverted nipples
21120 Genioplasty; augmentation (autograft, allograft, prosthetic material)
21121 Genioplasty; sliding osteotomy, single piece
21122 Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin)
21123 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)
Code Description
Cosmetic Services
40500 Vermilionectomy (lip shave), with mucosal advancement
56620 Vulvectomy simple; partial
69300 Otoplasty, protruding ear, with or without size reduction
HCPCS
Q2026 Injection, Radiesse, 0.1 ml
Q2028 Injection, sculptra, 0.5 mg
Code Description
Cosmetic / Reconstructive
CPT
11970 Replacement of tissue expander with permanent prosthesis
11971 Removal of tissue expander(s) without insertion of prosthesis
19316 Mastopexy
19324 Mammaplasty, augmentation; without prosthetic implant
19325 Mammaplasty, augmentation; with prosthetic implant
19328 Removal of intact mammary implant
19330 Removal of mammary implant material
19340 Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
19342 Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
19350 Nipple/areola reconstruction
19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion
19366 Breast reconstruction with other technique
19370 Open periprosthetic capsulotomy, breast
19371 Periprosthetic capsulectomy, breast
19380 Revision of reconstructed breast
Code Description
Cosmetic / Reconstructive
21088 Impression and custom preparation; facial prosthesis
21188 Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts)
21280 Medial canthopexy (separate procedure)
21282 Lateral canthopexy
Code Description
Non-covered Services
CPT
17380 Electrolysis epilation, each 30 minutes
69090 Ear piercing
Note: CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS).
Related Information
Definition of Terms
When specific definitions are not present in a member’s plan, the following definitions will be applied. Cosmetic: In this policy, cosmetic services are those which are primarily intended to preserve or improve appearance. Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient’s appearance or self-esteem.
Physical functional impairment: In this policy, physical functional impairment means either limitation from normal physical functioning or baseline level of functioning that may include, but is not limited to, problems with ambulation, mobilization, communication, respiration, eating, swallowing, vision, facial expression, skin integrity, distortion of nearby body part(s) or obstruction of an orifice. The physical functional impairment can be due to structure, congenital deformity, pain, or other causes. Physical functional impairment excludes social, emotional and psychological impairments or potential impairments.
Reconstructive surgery: In this policy, reconstructive surgery refers to surgeries 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.
Determination of Eligibility for Coverage
The final determination of eligibility for coverage should be based on application of the specific contract language based on the etiology of the defect and the presence or absence of documented physical functional impairment.
Administering the Contract Language (also see Benefit Application) The following general principles describe the issues to be determined in properly administering the contract language.
1. The eligibility of a service for coverage may be based on either a specific benefit addressing cosmetic or reconstructive services or on its specific exemption or exclusion for cosmetic or reconstructive services or both.
2. Cosmetic services are usually considered to be those that are primarily to restore appearance and that otherwise do not meet the definition of reconstructive. The definition of reconstructive may be based on two distinct factors:
o Whether the service is primarily indicated to improve or correct a functional impairment or is primarily to improve appearance; and
o The etiology of the defect (eg, congenital anomaly, anatomic variant, result of trauma, post-therapeutic intervention, disease process).
3. The presence or absence of a functional impairment is a critical point in interpreting coverage eligibility. For musculoskeletal conditions, the concept of a functional impairment is straightforward. However, when considering dermatologic conditions, the function of the skin is more difficult to define. Procedures designed to enhance the appearance of the skin are typically considered cosmetic.
Benefit Application
Considerations when reviewing a case: Contract language may vary regarding the definition of reconstructive services for different categories of conditions. Two key considerations are listed below:
• First, it must be determined whether a functional impairment is present that would render its treatment medically necessary and thus eligible for coverage if no other exclusions apply.
• Second, if no functional impairment is present, the etiology of the condition must be determined and the contract language reviewed to see if this etiology is included in the definition of reconstructive services.
Evidence Review
This policy was reviewed by consensus without literature review.
Description
The coverage of medical and surgical therapies to treat musculoskeletal abnormalities and abnormalities of the integumentary system are often based on a determination of whether the abnormality is considered reconstructive or cosmetic in nature.
While reconstructive is often taken to mean that the service “returns the patient to whole” and cosmetic is often interpreted as meaning the restoration of appearance only, the application of these terms must be based on specific contract language that often varies from those in the
Definition of Terms section.
Cosmetic Genital Procedures
Vaginal procedures referred to as “rejuvenation” surgery are generally considered cosmetic as most are performed for aesthetic reasons to enhance appearance. Labia reduction surgery, also known as labiaplasty, removes excess skin or reshapes the labia, or vaginal lips. In the absence of genital mutilation, cancer, or traumatic injury a labiaplasty is cosmetic surgery. According to an American College of Obstetricians and Gynecologists (ACOG) committee opinion statement from 20075
, “these procedures are not medically indicated, and the safety and effectiveness of
these procedures have not been documented.” (See Related Medical Policies for procedures that are under gender reassignment surgery.)
Injectable Dermal Fillers
The FDA has approved a number of injectable dermal fillers and volume-producing agents for treatment localized to the face in order to create a smoother appearance. These include, but are not limited to the following:
• Calcium hydroxylapatite microsphere (Radiesse®)
• Hyaluronic acid (Restylane®, Perlane®, Juvederm® Ultra, Elevess™, Prevelle® Silk,
Teosyal®, Revanesse® Ultra)
• Poly-L-lactic acid (Sculptra®)
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