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FAQ Coverage Determination Guidelines for Cosmetic and

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					       Coverage Determination Guidelines for Cosmetic and Reconstructive
       Procedures
       Frequently Asked Questions (FAQs)
       ____________________________________________________________________

          What are Coverage Determination Guidelines (CDGs)?
          How are the Coverage Determination Guidelines for cosmetic and reconstructive procedures
           changing?
          What procedures are impacted by the new clinical coverage review requirements?
          What documentation will be required to fulfill the new clinical coverage review requirement for
           these procedures?
          How do I obtain a copy of the Coverage Determination Guidelines (CDG)?
          How do I submit the required documentation?
          Can the clinical documentation be submitted on a CD?
          What will happen if the required documentation is not submitted?
          If a positive coverage determination was made for services to be provided on or after Dec. 1, 2010,
           is the surgeon required to submit new material for that case?
          What constitutes a high-quality photograph/print?
          How were physicians notified of this change?
          Can a coverage determination decision be appealed?
       ____________________________________________________________________

       What are Coverage Determination Guidelines (CDGs)?
       CDGs are benefit interpretation documents that provide guidance for coverage determinations for
       medical service categories described in the members’ plan documents through either the Certificates of
       Coverage for fully insured customers or the Summary Plan Descriptions for self-funded (ASO)
       customers. Such medical service categories include (among other services) skilled or custodial care,
       proven or investigational or unproven services, and reconstructive or cosmetic services. The CDGs
       identify the applicable plan language and the way in which clinical criteria are applied to make
       coverage determinations. Although plan benefit language may vary, the clinical criteria applied to a
       specific service remain the same.

       The plan language provides that, in order to be covered as reconstructive, three basic criteria must be
       met:

          There must be a specified and well-defined physical or physiologic abnormality.
          The abnormality must be causing a functional impairment.
          The impairment must be likely to be significantly improved by the proposed treatment.

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       How are the Coverage Determination Guidelines for cosmetic and reconstructive procedures
       changing?
       Beginning Dec. 1, 2010, physicians are required to submit additional and/or more detailed clinical
       information in order to fulfill the clinical coverage review requirement for these services. See question
       below for new documentation requirements.

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Doc#: UHC0553z_122010
       What procedures are impacted by the new clinical coverage review requirements?
       The new clinical coverage review requirements apply to the following procedures/codes:

       BLEPHAROPLASTY, BROW PTOSIS REPAIR, CANTHOPEXY AND OTHER EYE
       PROCEDURES: Refer to the CDG titled Blepharoplasty, Blepharoptosis, and Brow Ptosis
       Repair for additional codes and related coverage criteria.
           CPT
                                                     Description
          Code
         21280     Medial canthopexy (separate procedure)
         21282     Lateral canthopexy
                   Correction of lagophthalmos, with implantation of upper eyelid lid load (e.g.,
         67912
                   gold weight)
       BREAST RECONSTRUCTION--POST MASTECTOMY: Refer to the CDG titled Breast
       Reconstruction Post Mastectomy for the list of applicable codes and related coverage
       criteria.
                   Mastopexy (This code is cosmetic except when used post-mastectomy; Refer
         19316
                   to the CDG titled Breast Reconstruction Post Mastectomy)
       BREAST REDUCTION: Refer to the CDG titled Breast Reduction Surgery for the list of
       applicable codes and related coverage criteria.
       BREAST REPAIR/RECONSTRUCTION NOT FOLLOWING MASTECTOMY: Refer to the
       CDG titled Breast Repair/Reconstruction (Not Following Mastectomy) for the list of
       applicable codes and related coverage criteria.
       CRANIOFACIAL PROCEDURES
         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 superior-lateral orbital rim and lower forehead, advancement
         21172
                   or alteration, with or without grafts (includes obtaining autografts)
                   Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead,
         21175     advancement or alteration (e.g., plagiocephaly, trigonocephaly,
                   brachycephaly), with or without grafts (includes obtaining autografts)
                   Reconstruction, entire or majority of forehead and/or supraorbital rims; with
         21179
                   grafts (allograft or prosthetic material)
                   Reconstruction, entire or majority of forehead and/or supraorbital rims; with
         21180
                   autograft (includes obtaining grafts)
                   Reconstruction by contouring of benign tumor of cranial bones (e.g., fibrous
         21181
                   dysplasia), extracranial
                   Reconstruction of orbital walls, rims, forehead, nasoethmoid complex
                   following intra- and extracranial excision of benign tumor of cranial bone
         21182
                   (e.g., fibrous dysplasia), with multiple autografts (includes obtaining grafts);
                   total area of bone grafting le
                   Reconstruction of orbital walls, rims, forehead, nasoethmoid complex
                   following intra- and extracranial excision of benign tumor of cranial bone
         21183
                   (e.g., fibrous dysplasia), with multiple autografts (includes obtaining grafts);
                   total area of bone grafting
                   Reconstruction of orbital walls, rims, forehead, nasoethmoid complex
                   following intra- and extracranial excision of benign tumor of cranial bone
         21184
                   (e.g., fibrous dysplasia), with multiple autografts (includes obtaining grafts);
                   total area of bone grafting
                   Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic
         21208
                   implant)
         21209     Osteoplasty, facial bones; reduction
         21230     Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining
Doc#: UHC0553z_122010
                    graft)
        21235       Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)
                    Reconstruction of orbit with osteotomies (extracranial) and with bone grafts
         21256
                    (includes obtaining autografts) (e.g., micro-ophthalmia)
                    Periorbital osteotomies for orbital hypertelorism, with bone grafts;
         21260
                    extracranial approach
                    Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined
         21261
                    intra- and extracranial approach
                    Periorbital osteotomies for orbital hypertelorism, with bone grafts; with
         21263
                    forehead advancement
                    Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts;
         21267
                    extracranial approach
                    Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts;
         21268
                    combined intra- and extracranial approach
         21270      Malar augmentation, prosthetic material
         21275      Secondary revision of orbitocraniofacial reconstruction
                    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
         21299      Unlisted craniofacial and maxillofacial procedure
       DENTAL PROCEDURES
                    Reconstruction of mandible or maxilla, endosteal implant (e.g., blade,
         21248
                    cylinder); partial
                    Reconstruction of mandible or maxilla, endosteal implant (e.g., blade,
         21249
                    cylinder); complete
       GYNECOMASTIA: Refer to the CDG titled Gynecomastia for the list of applicable codes
       and related coverage criteria.
       ORTHOGNATHIC/JAW SURGERY: Refer to the CDG titled Orthognathic/Jaw Surgery
       for additional codes and related coverage criteria.
                    Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage
         21255
                    (includes obtaining autografts)
         21299      Unlisted craniofacial and maxillofacial procedure
       PANNICULECTOMY AND BODY CONTOURING PROCEDURES: Refer to the CDG titled
       Panniculectomy and Body Contouring Procedures for the list of applicable codes and
       related coverage criteria.
       PECTUS EXCAVATUM RECONSTRUCTIVE REPAIR PROCEDURES: Refer to the
       Medical Policy titled Repair of Pectus Deformities for additional codes and related
       coverage criteria.
         21740      Reconstructive repair of pectus excavatum or carinatum; open
                    Reconstructive repair of pectus excavatum or carinatum; minimally invasive
         21742
                    approach (nuss procedure), without thoracoscopy
                    Reconstructive repair of pectus excavatum or carinatum; minimally invasive
         21743
                    approach (nuss procedure), with thoracoscopy
       RHINOPLASTY, SEPTOPLASTY, TURBINATE RESECTION AND NOSE
       PROCEDURES: Refer to the CDG titled Rhinoplasty, Septoplasty, Repair of Vestibular
       Stenosis and Turbinate Resection for additional codes and related coverage criteria.
         30120      Excision or surgical planing of skin of nose for rhinophyma
         30540      Repair choanal atresia; intranasal
         30545      Repair choanal atresia; transpalatine
         30560      Lysis intranasal synechia
         30620      Septal or other intranasal dermatoplasty (does not include obtaining graft)
       VEINS: Refer to the CDG titled Ablative Procedures for Venous Insufficiency and Varicose
       Veins for additional codes and related coverage criteria. The following procedures/codes
       related to the treatment of spider veins are considered cosmetic; the codes do not

Doc#: UHC0553z_122010
       improve a functional physical or physiological impairment.
                   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
       MISCELLANEOUS COSMETIC AND RECONSTRUCTIVE PROCEDURES
       The following codes are considered cosmetic; the codes do not improve a functional, physical or
       physiological impairment.
        11950       Subcutaneous injection of filling material (e.g., collagen); 1 cc or less
        11951       Subcutaneous injection of filling material (e.g., collagen); 1.1 to 5.0 cc
        11952       Subcutaneous injection of filling material (e.g., collagen); 5.1 to 10.0 cc
        11954       Subcutaneous injection of filling material (e.g., collagen); over 10.0 cc
        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 4 lesions or less (list separately in addition to code
        15787
                    for primary procedure)
        15788       Chemical peel, facial; epidermal
        15789       Chemical peel, facial; dermal
        15792       Chemical peel, nonfacial; epidermal
        15793       Chemical peel, nonfacial; dermal
        15819       Cervicoplasty
        15824       Rhytidectomy; forehead
        15825       Rhytidectomy; neck with platysmal tightening (platysmal flap, p-flap)
        15826       Rhytidectomy; glabellar frown lines
        15828       Rhytidectomy; cheek, chin, and neck
        15829       Rhytidectomy; superficial musculoaponeurotic system (smas) flap
        17380       Electrolysis epilation, each 30 minutes
        69090       Ear piercing
        69300       Otoplasty, protruding ear, with or without size reduction

        HCPCS
                                                        Description
         Code
        L8600       Implantable breast prosthesis, silicone or equal
                    Breast reconstruction with gluteal artery perforator (gap) flap, including
         S2066      harvesting of the flap, microvascular transfer, closure of donor site and
                    shaping the flap into a breast, unilateral
                    Breast reconstruction of a single breast with "stacked" deep inferior
                    epigastric perforator (diep) flap(s) and/or gluteal artery perforator (gap)
         S2067
                    flap(s), including harvesting of the flap(s), microvascular transfer, closure of
                    donor site(s) and shaping
                    Breast reconstruction with deep inferior epigastric perforator (diep) flap or
                    superficial inferior epigastric artery (siea) flap, including harvesting of the
         S2068
                    flap, microvascular transfer, closure of donor site and shaping the flap into a
                    breast, unilateral

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Doc#: UHC0553z_122010
       What documentation will be required to fulfill the new clinical coverage review requirement
       for these procedures?
       As outlined in the CDG, 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:
                  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:
                         i.   A well-defined physical and/or physiological abnormality resulting in a medical
                              condition that has required or requires treatment; and
                         ii. The physical and/or physiological abnormality has resulted in a functional deficit;
                             and
                         iii. The functional deficit is recurrent or persistent in nature.
                  B. Appropriate clinical studies/tests addressing the physical and/or physiological
                     abnormality that confirm its presence and the degree to which it is causing impairment
                  C. High-quality color photographs, where applicable, documenting the physical and/or
                     physiological abnormality accounting for the functional. 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).
                  D. Treating physician’s plan of care (proposed procedures), which must include the
                     expected outcome for the improvement of the functional deficit.

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       How do I obtain a copy of the Coverage Determination Guidelines (CDG)?
       The CDG is available at UnitedHealthcareOnline.com > Tools & Resources > Policies and Protocols >
       Medical & Drug Policies and Coverage Determination Guidelines > Cosmetic and Reconstructive
       Procedures

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       How do I submit the required documentation?

          Step 1: Provide Notification
           Prior to submitting any documentation for review, as part of our standard process, the provider
           must first initiate an advance notification request at UnitedHealthcareOnline.com or by calling 877-
           842-3210 and obtaining a service reference number. The member’s name and plan identification
           number may be used as an alternative to the service reference number.

          Step 2: Wait for Contact from UnitedHealthcare
           Upon receipt and review of the advance notification request, we will contact the provider by
           telephone and inform him/her of the applicable clinical documentation requirements and
           instructions for submitting the requested documentation.

          Step 3: Submit Documentation
           The required documentation may be submitted electronically in digital form (the preferred method)
           or by fax or hard copy. The service reference number obtained during the advance notification
           process must be included on all document submissions. Submission options include:

              Option 1: Secure E-mail Submission

Doc#: UHC0553z_122010
              The required documentation may be submitted via secure e-mail to CCR@uhc.com. This option
              provides the fastest processing. Please note the following:
                       Use of the secure e-mail system requires a one-time user registration and set-up
                        process.
                       The registration and set-up instructions will be provided to first-time users upon receipt
                        and review of their advance notification request.
                       Providers who wish to set up their account in advance may send an e-mail to
                        CCR@uhc.com and note the word “Setup” in the subject line of their e-mail. Upon
                        receipt, a system-generated response containing the registration and set-up instructions
                        will then be provided.
                       Providers will be required to include the service reference number obtained during the
                        advance notification process in the subject line of their e-mail prior to submission.
                       Upon submission of their e-mail, the provider will receive a system-generated delivery
                        receipt advising him/her to refer to UnitedHealthcareOnline.com for information on the
                        status of their request.

              Option 2: Fax Submission
              Fax the required documentation to 800-628-0654. The service reference number obtained
              during the advance notification must be listed in the subject line of the fax cover sheet for
              proper routing. Please note that we cannot accept faxed photos that are not of sufficient
              quality.
              Option 3: Hardcopy Submission:
              Mail the required documentation to the following address. (Please note that the physical
              transfer of hard copy prints requires longer processing time, in addition to mailing time.)
                                           P.O. Box 30555
                                           Salt Lake City, UT 84130-0555

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       Can the clinical documentation be submitted on a CD?
       Yes, a CD may be submitted. However, each of the required documents must be saved as a
       separate/individual file to the CD (e.g., pictures must be saved separately from the office notes, etc.).
       A single PDF file reflecting multiple pieces of documentation cannot be accepted. Remember to include
       the member’s name and plan identification number on each document.

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       What will happen if the required documentation is not submitted?
       Upon review of the required clinical information/documentation, UnitedHealthcare will provide a
       coverage determination. Failure to submit the required documentation will result in an adverse
       coverage determination due to lack of clinical information.

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       If a positive coverage determination was made for services to be provided on or after Dec.
       1, is the surgeon required to submit new material for that case?
       No. In this situation, the coverage determination will stand. We will not revisit coverage decisions
       rendered prior to Dec. 1.

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Doc#: UHC0553z_122010
       What constitutes a high-quality photograph/print?
       Ideally, a high-quality print should have at least 200 pixels per inch. But, more importantly, it is
       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.

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       How were physicians notified of this change?
       An announcement detailing the new CDG and related documentation requirements was made in the
       July 2010 Network Bulletin and the September 2010 Network Bulletin.

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       Can a coverage determination decision be appealed?
       Yes. An appeal may be filed if a physician disagrees with the outcome of the coverage determination.
       The complete appeal process will be explained in the coverage determination letter.

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Doc#: UHC0553z_122010

				
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