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COSMETIC _ RECONSTRUCTIVE SURGERY and DEFINITIONS

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COSMETIC _ RECONSTRUCTIVE SURGERY and DEFINITIONS Powered By Docstoc
					                COSMETIC & RECONSTRUCTIVE SURGERY
                          and DEFINITIONS
Protocol: SUR040
Effective Date: April 11, 2011

Table of Contents

COMMERCIAL COVERAGE RATIONALE......................................................................................... 1
COMMERCIAL COVERAGE: REQUIRED DOCUMENTATION ...................................................... 3
MEDICARE COVERAGE RATIONALE............................................................................................. 12
MEDICAID COVERAGE RATIONALE.............................................................................................. 16
DEFINITIONS ....................................................................................................................................... 17
APPLICABLE CODES - COMMERCIAL............................................................................................ 21
APPLICABLE CODES - MEDICARE.................................................................................................. 26
REFERENCES ....................................................................................................................................... 33
PROTOCOL HISTORY/REVISION INFORMATION ........................................................................ 34

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.

For further information see:
Protocol SUR018 – BREAST REDUCTION SURGERY
Protocol SUR050 – BLEPHAROPLASTY & 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
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.




Cosmetic & Reconstructive Surgery & Definitions                                                                                      Page 1 of 34
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.

Additional Information
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 implant 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, modified 2009)

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)
   • Surgery to correct a malformation of the midface when done to correct a present or future
        impairment.
This list is necessarily incomplete.




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COMMERCIAL COVERAGE: REQUIRED DOCUMENTATION
      I. 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 (NOT FOLLOWING MASTECTOMY)

I. Required Documentation
The decision regarding whether breast repair/reconstruction not following mastectomy will be covered
as reconstructive and medically necessary or excluded from coverage as cosmetic; will require review
of the following clinical information and documentation, and such other documentation as may be
reasonably requested:
 1.      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;
            i. Contemporaneous office notes describing the member’s chief complaint, history of the
               complaint and physical exam, and
            ii. Documentation from the notes that the condition is the primary etiology of the
                member’s functional impairment, which is specifically described, and
            iii. Evidence that the functional impairment is recurrent or persistent in nature, and
 2.      Results of mammography, ultrasound or magnetic resonance imaging (MRI) studies that
         document the physical abnormality causing the impairment, and
 3.      When pain is the primary complaint, a completed pain questionnaire addressing the degree and
         severity of functional impairment (see below), and
 4.      High-quality color photographs documenting Baker III or IV capsular contracture. The date
         taken, the service reference identification number (obtained at time of notification), or patient’s
         name and ID number must be documented on the photograph (s), and
 5.      Treatment plan that must include proposed procedures and the expected outcome for the
         improvement of the functional impairment.


Note: Additional high-color photographs may be required if coverage determination cannot be
made.
II. Criteria for a Coverage Determination as Reconstructive
        A. Removal of a ruptured silicone gel breast implant is reconstructive regardless of the
            indication for the initial implant placement.
         B. Removal of breast implants with capsulectomy/capsulotomy for symptomatic capsular
            contracture is considered reconstructive when the following criteria are met:
            i. Baker grade III or IV capsular contracture


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             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)

             and either of the following
           ii. Moderate or severe pain as indicated by answers to pain questionnaire (see below), or
           iii. 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.
       C. Removal of a deflated saline breast implant shell is considered cosmetic unless the implants
          were done post-mastectomy.
       D. Correction of inverted nipples is considered reconstructive when either of the following
          criteria are met:
               1. Member meets the Women’s Health and Cancer Rights Act (WHCRA) criteria, or
               2. Documented history of chronic nipple discharge, bleeding, scabbing or ductal
                  infection.

       E. 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
          Coding section for a list of codes that meet the criteria for a reconstructed breast.

       F. Breast reconstruction done in conjunction with the repair of the chest wall deformity of
          Poland syndrome is reconstructive. Although no functional impairment may exist for the
          breast reconstruction for Poland syndrome, this has been deemed reconstructive surgery
          and will be continued to be deemed as such.

           Poland syndrome is a rare, nonfamilial anomalad of unknown cause. The components of
           the syndrome include absence of the pectoralis major muscle, absence of hypoplasis 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.

       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.



Cosmetic & Reconstructive Surgery & Definitions                                              Page 4 of 34
                             Pain Questionnaire
       Pain questionnaire
       1) Does the patient have contracture-related difficulty moving her upper arm during
          activities?

           If yes, list the specific activities. Examples include retrieving something from overhead,
           combing one’s hair, reaching out or above to grab something to stabilize oneself.

                          ________________________________________________

                          _________________________________________________

                          _________________________________________________

       2) Does the patient take over-the-counter medications (e.g., aspirin, ibuprofen, NSAIDS or a
           similar type of medication) or prescription medications for the pain?

           If yes, what is the medication and dosage?

                          _____________________________________

           If yes, how many days in a two week period of time did the patient take the medication?

                              a)   0 - 2 days (0)
                              b)   3 - 4 days (1)
                              c)   5 - 6 days (2)
                              d)   7 or more days (3)

                    Scale for question 2 above:
                    0 =no symptoms
                    1=mild
                    2=moderate
                    3=severe
           (If the member has a moderate or severe rating for question #2, she would meet the
           criteria.)




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GYNECOMASTIA

A. Required Documentation:
   The decision regarding whether treatment for gynecomastia will be covered as reconstructive or
   excluded from coverage as cosmetic will require review of all of the following clinical
   information/documentation:
   Contemporaneous physician office notes with the history of the medical condition(s) requiring the
   treatment or surgical intervention. This documentation must include the following:
     1. Frontal and lateral high-quality color photographs of the torso with the patient’s name and
         date.
     2. Treatment plan that must include the proposed procedures and the expected outcome for the
         improvement of the breast pain.
     3. Documentation of the criteria listed in section B below.

B. Criteria for a Coverage Determination as Reconstructive:
   Mastectomy for gynecomastia is considered reconstructive when all of the following criteria are
   present:
     1. Male patient under age 18:
        In most cases breast enlargement and/or benign gynecomastia spontaneously resolves by age
        18 making treatment unnecessary. Monitoring should be considered. History of prescribed
        medications and screening of non-prescription medications or substances that have a known
        side effect of gynecomastia should be pursued. If a functional impairment is present as
        defined below, a clinical review is required to determine if it meets reconstructive criteria.
     2. Male patient age 18 and up:
         i. Documentation in the contemporaneous physician office notes that indicates:
            Discontinuation of medications, nutritional supplements, and non-prescription medications
            or substances that have a known side effect of gynecomastia or breast enlargement and the
            breast size did not regress in 8-12 weeks, and

         Note: Fatty deposits in breast area are not considered functional/physiological impairments
         and are not reconstructive, and is therefore not covered.

         ii.      There are no other medical causes for gynecomastia, as indicated by normal results for
                  all of the following:
                2) Serum creatinine
                3) Liver enzymes
                4) Thyroid function tests
                5) Hormone evaluation (eg, testosterone, LH, FSH, estradiol, prolactin, beta HCG)

         iii.    There is a functional impairment or physiological impairment that causes restriction or
                 impairment of basic life functions, meeting the definition of a functional impairment.
                 The impairment must result 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.


Cosmetic & Reconstructive Surgery & Definitions                                                Page 6 of 34
   (Note: the inability to participate in athletic events, sports, or social activities is not considered to
   be a functional or physiological impairment.)

PANNICULECTOMY & BODY CONTOURING PROCEDURES

Required Documentation:
The decision regarding whether the requested procedure will be covered as a reconstructive and
medically necessary procedure or excluded from coverage as cosmetic will require review of the
following required clinical information/documentation:

 A. Contemporaneous physician office notes with the history of the medical condition(s) requiring
    treatment or surgical intervention. This documentation must include either i or ii:
           i. The enrollee has a large abdominal panniculus that has resulted in a medical condition,
               that the physician has specified, that requires treatment, or
           ii. Documentation in the physician office notes that the large hanging panniculus causes a
               functional impairment (as defined in the Definitions section below).
 B. High quality color photographs documenting the hanging panniculus accounting for the
    functional impairment (as defined in the Definitions section). The date taken and service
    reference identification number (obtained at the time of notification) or patient’s name and ID
    number must be documented on the photograph (s):
         i. Full frontal view with panniculus hanging, and
        ii. Full frontal view with panniculus elevated (need to be able to evaluate any skin damage
               under the pannus in this view), and
       iii. Full lateral view with panniculus hanging.
 C. Treating physician’s plan of care (all specific proposed procedures), which must include the
    expected outcome for the improvement of the functional impairment (as defined in the
    Definitions section below) such as the improvement of skin erosion following panniculectomy.

II. Criteria for a Coverage Determination as Reconstructive:
A. Panniculectomy is considered reconstructive when the following criteria are present:

       1. Panniculus must hang below symphysis pubis, and
       2. There has been breakdown and loss of functional integrity of the skin, as evidenced by
          frank transdermal ulcerations of the skin through the epidermis and into the true
          dermis under the panniculus, stage II-IV as defined by the National Pressure Ulcer
          Advisory Panel (NPUAP) (refer to staging below), and
       3. Documentation through office notes of a cellulitis of the panniculus which has required
          systemic antibiotic treatment.

Or, if criteria 1, 2 and 3 above are not met, criteria 1 and 2 below must be met:

       1. Panniculus must hang below symphysis pubis, and
       2. Documentation in the physician office notes that the large hanging panniculus causes a
          functional impairment (as defined in the Definitions section below).



Cosmetic & Reconstructive Surgery & Definitions                                                   Page 7 of 34
Note: Staging definitions for pressure ulcers are as follows: (National Pressure Ulcer Advisory Panel,
2007):

Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence.
Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound
bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are
not exposed. Slough may be present but does not obscure the depth of tissue loss. May include
undermining and tunneling.

Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be
present on some parts of the wound bed. Often includes undermining and tunneling.

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, and/or
   3. Performed post childbirth in order to return to pre-pregnancy shape, and/or
   4. Performed for intertrigo, a superficial inflammatory response or any other condition that does
      not meet the criteria above in this document.

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, and/or
       2. Performed for diastasis recti, and/or
       3. When performed in conjunction with abdominal or gynecologic surgery including but not
           limited to hernia repair, obesity surgery, C-section and hysterectomy, and/or
       4. No documentation in the physician’s office notes 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

E. Suction Assisted Lipectomy of the Trunk (CPT code 15877) is not considered reconstructive,
and is not a covered service. However, benefits may be provided under federal mandate as follows:




Cosmetic & Reconstructive Surgery & Definitions                                             Page 8 of 34
       1. When performed to post-mastectomy patients to achieve symmetry as supported under the
          Women’s Health and Cancer Rights Act of 1998.

RHINOPLASTY, SEPTOPLASTY and REPAIR OF VESTIBULAR STENOSIS

I. Required Documentation
The decision regarding whether the requested procedure will be covered as reconstructive and
medically necessary or excluded from coverage as cosmetic will require review of the following
required clinical information/documentation:

         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;
             o Chief complaint from initial visit, and
             o Comprehensive and detailed history of the nasal symptoms requiring treatment or
               surgical intervention, and
             o Documentation (examples include approximate dates, types, duration, and outcomes
               of therapy of the medical treatments for symptoms, such as antihistamine,
               decongestants, intranasal corticosteroids, reversal of rebound congestion for over
               usage of intranasal decongestants, allergy consultation and treatments, antibiotic
               courses for chronic sinusitis (see definition section below), and nasal lavage, as
               applicable to the clinical presentation.

         B. Appropriate clinical studies/tests addressing the physical and/or physiologic abnormality
            that confirm its presence and the degree to which it is causing impairment:
             o Formal, signed computed tomography (CT) report of maxillo-facial/nasal sinus area,
               or
             o Any other tests that document the septal deviation

         C. In cases of post-traumatic nasal deformity, the following are required:
             o Formal, signed computed tomography (CT) report of maxillo-facial/nasal sinus area,
               or
             o Single high quality color photograph demonstrating the severe lateral displacement of
               the nose. The date 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), and
             o Contemporaneous office notes documenting the internal examination of the nose
               using a nasal speculum that documents in the medical record moderate or severe
               anterior septal deviation. (Please note that for patients with post-traumatic nasal
               deformity, clinical information in (A) and (B) above must be submitted).




Cosmetic & Reconstructive Surgery & Definitions                                             Page 9 of 34
         D. Treating physician’s plan of care for the proposed procedure (s) which must include the
            expected outcome for the improvement of the functional impairment (as defined in the
            Definitions section below):
             o Alleviate anatomical mechanical nasal airway obstruction
             o Increase air flow

II. Criteria for a Coverage Determination to be Reconstructive:

All of the following needs to be documented in contemporaneous office notes:

A. Septoplasty is considered reconstructive when all of the following criteria are present:
   1. Documentation of:
         a. Obstructive sleep apnea as confirmed by a polysomnogram showing an apnea hypopnea
             index (AHI) of 5 or greater and intolerance to CPAP or APAP due to nasal obstruction
             caused by nasal septal deviation. When an AHI result is not available or reported, a
             respiratory disturbance index (RDI) of 5 or greater would also be acceptable; or
         b. chronic sinusitis (see definition below); or
         c. consistent prolonged subjective difficulty breathing through the nose resulting in
             chronic mouth breathing and xerostomia with documentation of the side of obstruction,
             constant pattern, time frame of symptoms, exacerbating and mitigating factors of nasal
             obstruction, and

   2. A formal and signed written CT report stating that there is moderate or severe anterior
      (primarily cartilaginous) septal deviation, or

       In cases where the member or physician has declined a CT scan of the maxillo-facial and nasal
       region to document anterior (primarily cartilaginous) septal deviation, review of the records
       required above must show, in addition to meeting criteria 1, 3 and 4 of this section:
           a. That the condition has been chronic (>6 months) in duration, or that the member has
               had recurrent acute sinusitis episodes (see definition section); and
           b. The primary care records (if available) and specialist records are consistent as to
               symptoms, treatment, and the side that is involved in anatomic narrowing.

   3. Internal exam of the nose that documents in the medical record moderate or severe anterior
      (primarily cartilaginous) septal deviation.

   4. Documentation (examples include approximately dates, types, duration, and outcomes of
      therapy) of the medical treatments for symptoms, such as antihistamine, decongestants,
      intranasal corticosteroids, reversal of rebound congestion for over usage of intranasal
      decongestants, allergy consultation and treatments, antibiotic courses for chronic sinusitis, and
      nasal lavage, as applicable to the clinical presentation.

   5. In cases of post-traumatic nasal deformity, a formal, signed CT report of maxillo-facial/nasal
      sinus area, must document moderate or severe cartilaginous septal displacement; or



Cosmetic & Reconstructive Surgery & Definitions                                            Page 10 of 34
Single high quality color photograph (full face) demonstrating the severe lateral displacement of the
nose must be submitted. The date taken 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); and

Contemporaneous notes documenting the internal examination of the nose that documents in the
medical record moderate or severe anterior (primarily cartilaginous) septal deviation.

B. Septoplasty with endoscopic sinus surgery (see definition section below) requires review of the
   CT report and specialist treatment records. The CT report and treatment records must be consistent
   with significant septal deviation.

C. Septoplasty for posterior septal deviation or septal spur: Posterior septal deviation is
   considered reconstructive when associated with anterior (primarily cartilaginous) septal deviation,
   when the treatment of anterior (primarily cartilaginous) septal deviation addresses a physiologic
   function impairment. In the absence of anterior (primarily cartilaginous) septal deviation that
   causes a physiologic functional impairment, isolated posterior septal deviation generally does not
   cuse a physiologic function impairment. Isolated septal spurs generally do not cause a physiologic
   functional impairment.

D. Repair of nasal vestibular stenosis is considered reconstructive when all of the following criteria
   are present:
   1. Prolonged, persistent obstructed nasal breathing, and
   2. Worm’s eye view photographs confirming vestibular stenosis (this view is from the bottom of
       the nasal septum pointing upwards), and
   3. Physical examination confirming moderate to severe vestibular obstruction.

E. Rhinoplasty for a nasal deformity when a functional impairment exists may be considered
   reconstructive when performed in conjunction with correction of cleft lip, cleft palate, or
   combinations of the two.

Additional Information:
   • Rhinoplasty is not considered reconstructive.
   • Septorhinoplasty is not considered reconstructive, because it contains a cosmetic service,
     Rhinoplasty.

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:

       1. 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


Cosmetic & Reconstructive Surgery & Definitions                                            Page 11 of 34
              b. The physical and/or physiological abnormality has resulted in a functional deficit;
                  and
              c. The functional deficit is recurrent or persistent in nature
       2. Appropriate clinical studies/tests addressing the physical and/or physiological abnormality
          that confirm its presence and the degree to which it is causing impairment ;
       3. High-quality color photographic prints documenting the physical and/or physiological
          abnormality accounting for the functional impairment. The enrollee’s identification must be
          documented on the photograph using either name or health plan identification number
       4. Treating physician’s plan of care (proposed procedures), which must include the expected
          outcome for the improvement of the functional deficit.

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 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 (L28291). The Local
Coverage Determination is as follows:

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 & Reconstructive Surgery & Definitions                                            Page 12 of 34
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
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, 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.


Cosmetic & Reconstructive Surgery & Definitions                                              Page 13 of 34
     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.),
     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


Cosmetic & Reconstructive Surgery & Definitions                                           Page 14 of 34
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
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 are addressed in a separate LCD Blepharoplasty, Blepharoptosis and Brow Lift, located at
www.PalmettoGBA.com/J1

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


Cosmetic & Reconstructive Surgery & Definitions                                             Page 15 of 34
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.

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 case-
by-case basis.

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

See the Medicare Benefit Manual (Pub.100-2), Chapter 16, 120 - Cosmetic Surgery at
http://www.cms.hhs.gov/manuals/Downloads/bp102c16.pdf.

120 - Cosmetic Surgery
(Rev. 1, 10-01-03)
A3-3160, HO-260.11, B3-2329
Cosmetic surgery or expenses incurred in connection with such surgery is not covered. Cosmetic
surgery includes any surgical procedure directed at improving appearance, except when required for
the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the
functioning of a malformed body member. For example, this exclusion does not apply to surgery in
connection with treatment of severe burns or repair of the face following a serious automobile
accident, or to surgery for therapeutic purposes which coincidentally also serves some cosmetic
purpose.

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

Program payment may be made for the following procedures:

Medically necessary cosmetic surgery
  1. To correct birth defects in newborns, or
  2. To restore physical function after an injury, or
  3. Breast reconstructive surgery begun within three years following a mastectomy (breast removal
      or partial removal), or
  4. For any other cosmetic surgery mandated by Nevada Medicaid.




Cosmetic & Reconstructive Surgery & Definitions                                               Page 16 of 34
Exclusions include:
   1. Medically unnecessary cosmetic procedures (performed only to improve the way a participant
       looks or feels about him/herself), or
   2. 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 non-covered services:
      1. 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:
      1. Facelift/wrinkle removal (rhytidectomy),
      2. Nose hump correction,
      3. Moonface,
      4. 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.


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 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.

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.




Cosmetic & Reconstructive Surgery & Definitions                                            Page 17 of 34
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.

Cartilaginous Septal Deviation: Anterior nasal septum including the dorsal and caudal borders

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)
       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 themiddle 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. 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 implant 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, modified 2009)

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."

Ectropion: a medical condition in which the lower eyelid turns outwards.



Cosmetic & Reconstructive Surgery & Definitions                                               Page 18 of 34
Entropion: a medical condition in which the eyelids fold inward.

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.

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.

Gynecomastia: Gynecomastia, gynecomasty [gyneco+G.mastos, breast] Excessive development of the
male mammary glands due mainly to ductal proliferation with periductal edema: frequently secondary
to increased estrogen levels, mild g. 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, modified 2009).

Injury: means physical damage to the body inflicted by a foreign object, force, temperature, or
corrosive chemical. (HPN Generic Evidence of Coverage, modified 2009)

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.




Cosmetic & Reconstructive Surgery & Definitions                                              Page 19 of 34
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, rhinolaryngoscopy, rhinopharyngoscopy or rhinoscopy, is
the use of a flexible fiberoptic endoscope to evaluate upper airways (nasal passages, nasopharynx,
oropharynx, and larynx).

Nasal Vestibular Stenosis: is defined as a narrowing of the nasal inlet resulting in airway obstruction.
Causes include nasal trauma, infection, and iatrogenic insults.

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 theabdominal
cavity. It can be a result of morbid obesity and can be mistaken for a tumor or hernia.

Reconstructive Procedures: defined under cosmetic surgery.

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.

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.

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.

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.


Cosmetic & Reconstructive Surgery & Definitions                                             Page 20 of 34
Visual Field: The total area where objects can be seen in the peripheral vision while the eye is focused
on a central point.

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 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 non-covered health
service. Coverage is determined by the benefit document. This list of codes may not be all inclusive.

     CPT® Code            Description
                          Tattooing, intradermal introduction of insoluble opaque pigments to correct
        11920
                          color defects of skin, including micropigmentation; 6.0 sq cm or less
                          Tattooing, intradermal introduction of insoluble opaque pigments to correct
        11921
                          color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm
                          Tattooing, intradermal introduction of insoluble opaque pigments to correct
        11922             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 (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 10.0 cc
                          Insertion of tissue expander(s) for other than breast, including subsequent
        11960
                          expansion
        11970             Replacement of tissue expander with permanent prosthesis
        11971             Removal of tissue expander(s) without insertion of prosthesis
        15775             Punch graft for hair transplant; 1 to 15 punch grafts
        15776             Punch graft for hair transplant; more than 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 four lesions or less (List separately in addition to
        15787
                          code 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


Cosmetic & Reconstructive Surgery & Definitions                                              Page 21 of 34
      15820          Blepharoplasty, lower eyelid;
      15821          Blepharoplasty, lower eyelid; with extensive herniated fat pad
      15822          Blepharoplasty, upper eyelid;
      15823          Blepharoplasty, upper eyelid; with excessive skin weighting down lid
      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
Body Contouring Procedures
                     Excision, excessive skin and subcutaneous tissue (includes lipectomy);
      15830
                     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
                     Destruction of cutaneous vascular proliferative lesions (e.g., laser technique);
      17106
                     less than 10 sq cm
                     Destruction of cutaneous vascular proliferative lesions (e.g., laser technique);
      17107
                     10.0 to 50.0 sq cm
                     Destruction of cutaneous vascular proliferative lesions (e.g., laser technique);
      17108
                     over 50.0 sq cm
      17380          Electrolysis epilation, each 30 minutes
 Gynecomastia Code
      Section
      19300          Mastectomy for gynecomastia
      19316          Mastopexy
      19318          Reduction mammaplasty
      19324          Mammaplasty, augmentation; without prosthetic implant
      19325          Mammaplasty, augmentation; with prosthetic implant


Cosmetic & Reconstructive Surgery & Definitions                                          Page 22 of 34
        19328          Removal of intact mammary implant
        19330          Removal of mammary implant material
Breast Reconstruction Codes
        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
The following CPT codes meet the criteria for breast reconstruction
                       Immediate insertion of breast prosthesis following mastopexy, mastectomy or
        19340
                       in reconstruction
                       Delayed insertion of breast prosthesis following mastopexy, mastectomy or in
        19342
                       reconstruction
        19350          Nipple/areola reconstruction
                       Breast reconstruction, immediate or delayed, with tissue expander, including
        19357
                       subsequent expansion
        19361          Breast reconstruction with latissimus dorsi flap, without prosthetic implant
        19364          Breast reconstruction with free flap
        19366          Breast reconstruction with other technique
                       Breast reconstruction with transverse rectus abdominis myocutaneous flap
        19367
                       (tram), single pedicle, including closure of donor site
                       Breast reconstruction with transverse rectus abdominis myocutaneous flap
        19368          (tram), single pedicle, including closure of donor site; with microvascular
                       anastomosis (supercharging)
                       Breast reconstruction with transverse rectus abdominis myocutaneous flap
        19369
                       (tram), double pedicle, including closure of donor site
        21120          Genioplasty; augmentation (autograft, allograft, prosthetic material)
        21121          Genioplasty; sliding osteotomy, single piece
                       Genioplasty; sliding osteotomies, 2 or more osteotomies (e.g., wedge excision
        21122
                       or bone wedge reversal for asymmetrical chin)
                       Genioplasty; sliding, augmentation with interpositional bone grafts (includes
        21123
                       obtaining autografts)
        21125          Augmentation, mandibular body or angle; prosthetic material
                       Augmentation, mandibular body or angle; with bone graft, onlay or
        21127
                       interpositional (includes obtaining autograft)
        21137          Reduction forehead; contouring only
                       Reduction forehead; contouring and application of prosthetic material or bone
        21138
                       graft (includes obtaining autograft)
        21139          Reduction forehead; contouring and setback of anterior frontal sinus wall
                       Reconstruction midface, LeFort I; single piece, segment movement in any
        21141
                       direction (e.g., for Long Face Syndrome), without bone graft
                       Reconstruction midface, LeFort I; 2 pieces, segment movement in any
        21142
                       direction, without bone graft
        21143          Reconstruction midface, LeFort I; 3 or more pieces, segment movement in


Cosmetic & Reconstructive Surgery & Definitions                                        Page 23 of 34
                         any direction, without bone graft
                         Reconstruction midface, LeFort I; single piece, segment movement in any
        21145
                         direction, requiring bone grafts (includes obtaining autografts)
                         Reconstruction midface, LeFort I; 2 pieces, segment movement in any
        21146            direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted
                         unilateral alveolar cleft)
                         Reconstruction midface, LeFort I; 3 or more pieces, segment movement in
        21147            any direction, requiring bone grafts (includes obtaining autografts) (e.g.,
                         ungrafted bilateral alveolar cleft or multiple osteotomies)
                         Reconstruction midface, LeFort II; anterior intrusion (e.g., Treacher-Collins
        21150
                         Syndrome)
                         Reconstruction midface, LeFort II; any direction, requiring bone grafts
        21151
                         (includes obtaining autografts)
                         Reconstruction midface, LeFort III (extracranial), any type, requiring bone
        21154
                         grafts (includes obtaining autografts); without LeFort I
                         Reconstruction midface, LeFort III (extracranial), any type, requiring bone
        21155
                         grafts (includes obtaining autografts); with LeFort I
                         Reconstruction midface, LeFort III (extra and intracranial) with forehead
        21159            advancement (e.g., mono bloc), requiring bone grafts (includes obtaining
                         autografts); without LeFort I
                         Reconstruction midface, LeFort III (extra and intracranial) with forehead
        21160            advancement (e.g., mono bloc), requiring bone grafts (includes obtaining
                         autografts); with LeFort I
                         Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy;
        21193
                         without bone graft
                         Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy;
        21194
                         with bone graft (includes obtaining graft)
                         Reconstruction of mandibular rami and/or body, sagittal split; without internal
        21195
                         rigid fixation
                         Reconstruction of mandibular rami and/or body, sagittal split; with internal
        21196
                         rigid fixation
        21198            Osteotomy, mandible, segmental;
        21206            Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)
                         Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic
        21208
                         implant)
        21209            Osteoplasty, facial bones; reduction
        21270            Malar augmentation, prosthetic material
        21280            Medial canthopexy (separate procedure)
        21282            Lateral canthopexy
                         Reduction of masseter muscle and bone (e.g., for treatment of benign
        21295
                         masseteric hypertrophy); extraoral approach
                         Reduction of masseter muscle and bone (e.g., for treatment of benign
        21296
                         masseteric hypertrophy); intraoral approach
        21740            Reconstructive repair of pectus excavatum or carinatum; open
        21742            Reconstructive repair of pectus excavatum or carinatum; minimally invasive


Cosmetic & Reconstructive Surgery & Definitions                                             Page 24 of 34
                         approach (Nuss procedure), without thoracoscopy
                         Reconstructive repair of pectus excavatum or carinatum; minimally invasive
        21743
                         approach (Nuss procedure), with thoracoscopy
       28344             Reconstruction, toe(s); polydactyly
       30120             Excision or surgical planing of skin of nose for rhinophyma
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 (e.g., spreader grafting, lateral nasal wall
       30465
                        reconstruction)
Septoplasty
                        Septoplasty or submucous resection, with or without cartilage scoring,
       30520
                        contouring or replacement with graft
Other procedures
                        Single or multiple injections of sclerosing solutions, spider veins
       36468
                        (telangiectasia); limb or trunk
                        Single or multiple injections of sclerosing solutions, spider veins
       36469
                        (telangiectasia); face
       36470            Injection of sclerosing solution; single vein
       36471            Injection of sclerosing solution; multiple veins, same leg
       40500            Vermilionectomy (lip shave), with mucosal advancement
       65760            Keratomileusis
       65765            Keratophakia
       65767            Epikeratoplasty
       67900            Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
                        Repair of blepharoptosis; frontalis muscle technique with suture or other
       67901
                        material (e.g., banked fascia)
                        Repair of blepharoptosis; frontalis muscle technique with autologous fascial
       67902
                        sling (includes obtaining fascia)
                        Repair of blepharoptosis; (tarso) levator resection or advancement, internal
       67903
                        approach
                        Repair of blepharoptosis; (tarso) levator resection or advancement, external
       67904
                        approach
                        Repair of blepharoptosis; superior rectus technique with fascial sling
       67906
                        (includes obtaining fascia)


Cosmetic & Reconstructive Surgery & Definitions                                             Page 25 of 34
                             Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection
         67908
                             (e.g., Fasanella-Servat type)
         67911               Correction of lid retraction
                             Correction of lagophthalmos, with implantation of upper eyelid lid load (e.g.,
         67912
                             gold weight)
         67950               Canthoplasty (reconstruction of canthus)
                             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
         69090               Ear piercing
         69300               Otoplasty, protruding ear, with or without size reduction
         69320               Reconstruction external auditory canal for congenital atresia, single stage
CPT® is a registered trademark of the American Medical Association.

    HCPCS Code               Description
      L8600                  Implantable breast prosthesis, silicone or equal


APPLICABLE CODES - MEDICARE

CPT®/HCPCS Codes             Description
                             Dermabrasion; TotalFace (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)
                             Excision, Excessive Skin and Subcutaneous Tissue (includes Lipectomy);
         15830
                             Abdomen, Infraumbilical Panniculectomy
                             Excision, Excessive Skin and Subcutaneous Tissue (includes Lipectomy);
         15832
                             Thigh
                             Excision, Excessive Skin and Subcutaneous Tissue (includes Lipectomy);
         15833
                             Leg
         15834               Excision, Excessive Skin and Subcutaneous Tissue (includes Lipectomy); Hip
                             Excision, Excessive Skin and Subcutaneous Tissue (includes Lipectomy);
         15835
                             Buttock
                             Excision, Excessive Skin and Subcutaneous Tissue (includes Lipectomy);
         15836
                             Arm
                             Excision, Excessive Skin and Subcutaneous Tissue (includes Lipectomy);
         15837
                             Forearm or Hand
         15838               Excision, Excessive Skin and Subcutaneous Tissue (includes Lipectomy);


Cosmetic & Reconstructive Surgery & Definitions                                               Page 26 of 34
                         Submental Fat Pad
                         Excision, Excessive Skin and Subcutaneous Tissue (includes Lipectomy);
        15839
                         Other Area
                         Excision, Excessive Skin and Subcutaneous Tissue (includes Lipectomy);
                         Abdomen (e.g., Abdominoplasty) (includes Umbilical Transposition and
        15847            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
        19316            Mastopexy
        19318            Reduction Mammaplasty
        19324            Mammaplasty, Augmentation; Without Prosthetic Implant
        19325            Mammaplasty, Augmentation; With Prosthetic Implant
        19328            Removal of Intact Mammary Implant
        19330            Removal of Mammary Implant Material
                         Immediate Insertion of Breast Prosthesis following Mastopexy, Mastectomy
        19340
                         or in Reconstruction
                         Delayed Insertion of Breast Prosthesis following Mastopexy, Mastectomy or
        19342
                         in Reconstruction
        19350            Nipple/Areola Reconstruction
        19355            Correction of Inverted Nipples
                         Breast Reconstruction, Immediate or Delayed, with Tissue Expander,
        19357
                         including Subsequent Expansion
        19361            Breast Reconstruction with Latissimus Dorsi Flap, without Prosthetic Implant
        19364            Breast Reconstruction with Free Flap
        19366            Breast Reconstruction with Other Technique
                         Breast Reconstruction with Transverse Rectus Abdominis Myocutaneous
        19367
                         Flap (TRAM), Single Pedicle, including Closure of Donor Site
                         Breast Reconstruction with Transverse Rectus Abdominis Myocutaneous
        19368            Flap (TRAM), Single Pedicle, including Closure of Donor Site, with
                         Microvascular Anastomosis (Supercharging)
                         Breast Reconstruction with Transverse Rectus Abdominis Myocutaneous
        19369
                         Flap (TRAM), Double Pedicle, including Closure of Donor Site
        19370            Open Periprosthetic Capsulotomy, Breast
        19371            Periprosthetic Capsulotomy, Breast
        19380            Revision of Reconstructed Breast
        19396            Preparation of Moulage for Custom Breast Implant
                         Rhinoplasty, Primary; Lateral and Alar Cartilages and/or Elevation of Nasal
        30400
                         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


Cosmetic & Reconstructive Surgery & Definitions                                         Page 27 of 34
         30430               Rhinoplasty, Secondary; Minor Revision (Small Amount of Nasal Tip Work)
                             Rhinoplasty, Secondary; Intermediate Revision (Bony Work with
         30435
                             Osteotomies)
         30450               Rhinoplasty, Secondary; Major Revision (Nasal Tip Work and Osteotomies)
CPT® is a registered trademark of the American Medical Association.

ICD-9 Codes that Support Medical Necessity
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 medical necessity:
Group 1
Dermabrasion (CPT® Codes 15780-15783)
  ICD-9 Codes that
  Support Medical            Description
     Necessity
       695.3                 Rosacea
                             Full-thickness skin loss due to burn (third degree nos) of unspecified site of
                             face and head – Deep necrosis of underlying tissues due to burn (deep third
    941.30 – 941.59
                             degree) of multiple sites (except eye) of face, head and neck with loss of a
                             body part
                             Full-thickness skin loss due to burn (third degree nos) of unspecified site of
    942.30 – 942.35
                             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
         942.39
                             sites of trunk
                             Deep necrosis of underlying tissues due to burn (deep third degree) of trunk
    942.40 – 942.45          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
         942.49
                             and multiple sites of trunk without loss of body part
                             Deep necrosis of underlying tissues due to burn (deep third degree) of
    942.50 – 942.55          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
         942.59
                             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
    943.30 – 943.36          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
         943.39
                             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
    943.40 – 943.46
                             underlying tissues due to burn (deep third degree) of scapular region without
                             loss of scapula


Cosmetic & Reconstructive Surgery & Definitions                                               Page 28 of 34
                         Deep necrosis of underlying tissues due to burn (deep third degree) of
        943.49
                         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
   943.50 – 943.56
                         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
        943.59
                         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
   944.30 – 944.58       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
   945.30 – 945.36       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
        945.39
                         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
   945.40 – 945.46
                         necrosis of underlying tissues due to burn (deep third degree) of thigh (any
                         part) without loss of thigh
                         Deep necrosis of underlying tissues due to burn (deep third degree) of
        945.49
                         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
   945.50 – 945.56
                         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
        945.59
                         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
        946.3
                         sites
                         Deep necrosis of underlying tissues due to burn (deep third degree) of
        946.4
                         multiple specified sites without loss of a body part
                         Deep necrosis of underlying tissues due to burn (deep third degree) of
        946.5
                         multiple specified sites with loss of a body part




Cosmetic & Reconstructive Surgery & Definitions                                            Page 29 of 34
Group 2 Abdominal Lipectomy/Panniculectomy
(CPT® Codes 15830, 15832, 15833, 15834, 15835, 15836, 15837 and 15847)

  ICD-9 Codes that
  Support Medical        Description
     Necessity
       031.1             Cutaneous diseases due to other mycobacteria
        035              Erysipelas
       039.0             Cutaneous actinomycotic infection
       040.0             Gas gangrene
                         Streptococcus infection in conditions classified elsewhere and of unspecified
        041.00
                         site streptococcus
                         Streptococcus infection in conditions classified elsewhere and of unspecified
        041.01
                         site streptococcus Group A
                         Streptococcus infection in conditions classified elsewhere and of unspecified
        041.02
                         site streptococcus Group B
                         Streptococcus infection in conditions classified elsewhere and of unspecified
        041.03
                         site streptococcus Group C
                         Streptococcus infection in conditions classified elsewhere and of unspecified
        041.04
                         site streptococcus Group D (enterococcus)
                         Streptococcus infection in conditions classified elsewhere and of unspecified
        041.05
                         site streptococcus Group G
                         Streptococcus infection in conditions classified elsewhere and of unspecified
        041.09
                         site other streptococcus
                         Staphylococcus infection in conditions classified elsewhere and of
        041.10
                         unspecified site staphylococcus unspecified
                         Methicillin susceptible staphylococcus aureus in conditions classified
        041.11
                         elsewhere and of unspecified site
                         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


Cosmetic & Reconstructive Surgery & Definitions                                            Page 30 of 34
                         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
         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 Medical        Description
     Necessity
       174.0             Malignant neoplasm of nipple and areola of female breast
       174.1             Malignant neoplasm of central portion of female breast
       174.2             Malignant neoplasm of upper-inner quadrant of female breast
       174.3             Malignant neoplasm of lower-inner quadrant of female breast
       174.4             Malignant neoplasm of upper-outer quadrant of female breast
       174.5             Malignant neoplasm of lower-outer quadrant of female breast
       174.6             Malignant neoplasm of axillary tail of female breast
       174.8             Malignant neoplasm of other specified sites of female breast
       174.9             Malignant neoplasm of breast (female) unspecified site
       175.0             Malignant neoplasm of nipple and areola of male breast
       175.9             Malignant neoplasm of other and unspecified sites of male breast


Cosmetic & Reconstructive Surgery & Definitions                                             Page 31 of 34
        198.2            Secondary malignant neoplasm of skin
        198.81           Secondary malignant neoplasm of breast
         217             Benign neoplasm of breast
        232.5            Carcinoma in situ of skin of trunk except scrotum
        233.0            Carcinoma in situ of breast
        238.3            Neoplasm of uncertain behavior of breast
        239.3            Neoplasm of unspecified nature of breast
        612.1            Disproportion of reconstructed breast
        996.54           Mechanical complication of breast prosthesis
        V10.3            Personal history of malignant neoplasm of breast
        V43.82           Breast replacement status
        V52.4            Fitting and adjustment of breast prosthesis and implant
        V58.42           Aftercare following surgery for neoplasm

Reduction Mammoplasty (CPT® Code 19318)
Two diagnoses are required for payment (One primary and one secondary).

     PRIMARY
  ICD-9 Codes that
                         Description
  Support 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 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.)




Cosmetic & Reconstructive Surgery & Definitions                                        Page 32 of 34
Group 5
Rhinoplasty (CPT® Codes 30400-30450)

  ICD-9 Codes that
  Support Medical        Description
     Necessity
       160.0             Malignant neoplasm of nasal cavities
       170.0             Malignant neoplasm of bones of skull and face except mandible
       172.3             Malignant melanoma of skin of other and unspecified parts of face
       173.3             Other malignant neoplasm of skin of other and unspecified parts of face
       195.0             Malignant neoplasm of head, face and neck
       212.0             Benign neoplasm of nasal cavities middle ear and accessory sinuses
       213.0             Benign neoplasm of bones of skull and face
       216.3             Benign neoplasm of skin of other and unspecified parts of face
       232.3             Carcinoma in situ of skin of other and unspecified parts of face
      478.19             Other disease of nasal cavity and sinuses
       802.0             Closed fracture of nasal bones
       802.1             Open fracture of nasal bones

Diagnoses that Support Medical Necessity
All ICD-9-CM codes listed above under ICD-9-CM Codes That Support Medical Necessity above.

ICD-9 Codes that DO NOT Support Medical Necessity
All ICD-9-CM codes not listed above under ICD-9-CM Codes That Support Medical Necessity above.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation


Diagnoses that DO NOT Support Medical Necessity
All ICD-9-CM codes not listed above under ICD-9-CM Codes That Support Medical Necessity above.


REFERENCES

American Society of Plastic Surgeons (ASPS). 2006 Quick Facts. Cosmetic and Reconstructive Plastic
Surgery Trends. 2007. Available at:
http://www.plasticsurgery.org/media/statistics/loader.cfm?url=/commonspot/security/getfile.cfm&Page
ID=23625. Accessed November 6, 2009.

Centers for Medicare and Medicaid Services. Palmetto GBA (01302) LCD for Plastic Surgery
(L28291) Effective Date September 02, 2008. Updated January 21, 2010. Accessed April 2010.

Coleman, W. Dermatologic therapy: New directions in surgical therapy. Dermatol Clin.
1998(Apr.);16(2): 253-259.


Cosmetic & Reconstructive Surgery & Definitions                                          Page 33 of 34
Eavey, R. Ear malformations: what a pediatrician can do to assist with auricular reconstruction. Ped
Clin North Am. 1996(Dec.);43(6): 1233-1244.

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.

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.

Nevada Dept. of Health & Human Services-Division of HealthCare Financing and Policy (DHCFP)
Medicaid Services Manual. Section 603, Effective January 01, 2010. Accessed April 2010.

Sabiston. Aesthetic Surgery. In Textbook of Surgery, 15th ed. 1997. W.B. Saunders Company.


PROTOCOL HISTORY/REVISION INFORMATION

         Date            Action/Description
      02/24/2011
      08/26/2010
      08/03/2010         Corporate Medical Affairs Committee
      04/23/2010
      03/20/2009

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 & Reconstructive Surgery & Definitions                                              Page 34 of 34

				
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