Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Rhytidectomy and/or Cervicoplasty With or Without Liposuction and/or Platysmaplasty
Policy #:MA11.075a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

RHYTIDECTOMY


When performed as a cosmetic service, rhytidectomy is not covered by the Company because cosmetic services are not covered by Medicare. Therefore, these procedures are not eligible for reimbursement consideration. However, rhytidectomy is considered medically necessary and, therefore, covered when there is facial asymmetry/skin laxity that is caused by any of the following:

  • Facial nerve paralysis (e.g., Bell's palsy, birth trauma)
  • Facial trauma and/or accident (e.g., facial fracture)
  • Disease (e.g., malignancy, Ehler-Danlos syndrome, with surgery for parotidectomy)

CERVICOPLASTY (WITH OR WITHOUT LIPOSUCTION AND/OR PLATYSMAPLASTY)

When performed as a cosmetic service, cervicoplasty with or without liposuction (removal of excess fat) and/or platysmaplasty (tightening of the skin muscles) is not covered by the Company and is not eligible for reimbursement consideration because cosmetic services are not covered by Medicare. However, cervicoplasty with or without liposuction and/or platysmaplasty is considered medically necessary, and, therefore, covered for individuals with any of the following:
  • Congenital neck deformities (e.g., midline cervical cleft [MCC])
  • Trauma and/or accident to the neck (e.g., burns or lacerations or when the procedure is part of an ongoing reconstruction plan)
  • Disease (e.g., after resection due to malignancy, cervical necrotizing fasciitis)

COSMETIC

When rhytidectomy and/or cervicoplasty with or without liposuction and/or platysmaplasty do not meet the medical necessity criteria listed in this policy, they are considered cosmetic services. Services that are cosmetic are not covered by the Company because cosmetic services are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

Services performed due to recent trauma and/or accident may be eligible for coverage when performed within a year of the event or within a year of the time at which the member’s healing and/or skeletal and somatic maturation reasonably allows for repair and is intended to restore a member to a pre-trauma and/or pre-accident state, except when not covered by Medicare.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

All requests for rhytidectomy and/or cervicoplasty (with or without liposuction and platysmaplasty) require review by the Company and must include both of the following:
  • Letter of medical necessity that documents medical history of pathology (e.g., facial paralysis, neck trauma and/or accident, malignancy, or congenital defect)
  • Facial and/or neck photograph(s) including frontal, obliques, laterals, and/or asymmetries

Policy Guidelines

There is no Medicare coverage criteria addressing this service; therefore, the Company policy is applicable.
The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, rhytidectomy and/or cervicoplasty with or without liposuction and/or platysmaplasty are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as cosmetic are not eligible for coverage or reimbursement by the Company.

Description

RHYTIDECTOMY (FACELIFT)

Rhytidectomy, also known as meloplasty or facelift, is a procedure by which facial wrinkles are excised and removed through plastic surgery. Rhytidectomy aims to correct or improve skin laxity, jowling, heavy nasolabial folds, submental and submandibular fat deposits, and platysma muscle bands. Treatment of these conditions is typically cosmetic in nature. Cosmetic services are those provided to improve an individual’s physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiologic function.

Published literature supports reconstructive rhytidectomy procedures that are performed to correct facial asymmetry/skin laxity due to facial nerve paralysis, trauma and/or accident, or known pathologic conditions of the skin associated with abnormal loss of elasticity. Reconstructive rhytidectomy is generally performed to improve function but may also be performed to approximate a normal appearance.

CERVICOPLASTY (NECK LIFT, NECK REJUVENATION)

A neck lift includes a set of surgical procedures that enhance the appearance of the neck. These may include liposuction to remove excess fat from neck, platysmaplasty to tighten or remove sagging neck muscle bands, and cervicoplasty to remove excess skin. After a neck lift, the individual will have a cosmetically sharper, more defined jaw line, with an improved neck and chin angle.

During the natural aging process, the skin of the face and neck lose elasticity, and underlying muscles also lose tone. Other factors such as sun exposure, weight gain or loss, and the natural forces of gravity may work to accelerate the appearance of loose skin, creating a tired look. A loose, wrinkly neck area may be referred to as a turkey neck or turkey wattle, jowls, or, when excess fat has settled in the neck area, a double chin.

Cervicoplasty can be done as a stand-alone procedure, but it is frequently done in combination with other elective cosmetic surgical procedures, such as forehead and/or brow lift, blepharoplasty (eyelid lift), chin and/or cheek augmentation with implants, rhinoplasty (nose reshaping), liposuction, chemical peel, laser resurfacing, and lipotransfer (fat redistribution).

There are many variations of cervicoplasty. Sometimes small incisions around the ears are used to retract the skin and muscle and provide a postoperative appearance where minimal scarring is visible. Anterior cervicoplasty is a more extensive procedure done with a midline neck incision, but this technique is reserved only for those who can tolerate a visible scar, and is reported to be performed more often in men than in women. In recent years, this procedure, coupled with a z-plasty closure, has produced a more esthetically pleasing result.

Current literature supports the use of cervicoplasty as part of a reconstructive plan in individuals who have had surgical resections due to disease or trauma and/or accident of the neck. Cervicoplasty may also be performed to repair rare congenital anomalies, such as a midline cervical cleft (MCC).
References

American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Face lift surgery. Understanding rhytidectomy. [AAFPRS Web site]. 2019. Available at: https://www.aafprs.org/patient/procedures/rhytidetomy.html. Accessed August 16, 2019.

American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Facial plastic surgery today newsletter 2008. [AAFPRS Web site]. 2019. Available at: https:// www.aafprs.org/patients/fps_today/vol22/02/pg4.html. Accessed August 16, 2019.

American Society of Plastic Surgeons (ASPS). Facelift. [ASPS Web site]. 2019. Available at: http://www.plasticsurgery.org/cosmetic-procedures/facelift.html. Accessed August 16, 2019.

American Society of Plastic Surgeons (ASPS). Necklift. [ASPS Web site]. 2019. Available at: http:www.plasticsurgeery.org/cosmetic-procedures/necklift.html. Accessed August 16, 2019.

Briggs RD. Rhytidectomy. Grand Rounds presentation [The University of Texas Medical Branch, Department of Otolaryngology Web site]. May 2003. Available at:https://pdfs.semanticscholar.org/78f7/ed0e5be32df3f68cd377975b54c56a6c9018.pdf?_ga=2.2749232.1037341813.1565966746-1370004598.1565966746 Accessed August 16, 2019.

Caplin DA, Perlyn CA. Rejuvenation of the aging neck: current principles, techniques, and newer modifications. Facial Plast Surg Clin North Am. 2009;17(4):589-601.

Carruthers A, Carruthers J. Botulinum toxin for cosmetic indications: treatment of specific sites. Up to Date.[UpToDate Web site]. 06/07/2019. Available at:
https://www.uptodate.com/contents/botulinum-toxin-for-cosmetic-indications-treatment-of-specific-sites. [via subscription only]. Accessed August 16, 2019.

Don Parsa F, Castel N, Niloufari Parsa N. A modified, direct neck lift technique: the cervical wave-plasty. Arch Plast Surg. 2016 Mar; 43(2):181-188. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4807173. Accessed August 16, 2019.

Hancox JG, Eaton JS. Anterior cervicoplasty:neck rejuvenation using local anesthesia. J Am Acad Dermatol 2008;58:430-433. Available at: https://www.jaad.org/article/S0190-9622(07)02398-5/pdf. Accessed August 16, 2019.

Kilpatrick JK, LaFerriere KA. Rhytidectomy, deep plane facelift. [eMedicine Web site]. 06/06/2019. Available at: http://emedicine.medscape.com/article/841704-overview. Accessed August 16, 2019.

Labbe D, Franco RG, Nicolas J. Platysma suspension and platysmaplasty during neck lift: anatomical study and analysis of 30 cases. Plast Reconstr Surg. 2006:117(6):2001-2010.

Marks MW, Marks C. Aesthetic facial surgery. In: Fundamentals of Plastic Surgery. 1st ed. Philadelphia, PA: WB Saunders Co; 1997:264-70.

Mercandetti M. Facelift, Cohen AJ. Facelift, SMAS Plication. [eMedicine Web site]. 05/15/2019. Available at: http://emedicine.medscape.com/article/1294486-overview. Accessed August 16, 2019.

Mun GH. Reconstruction of postburn neck contractures using free thin thoracodorsal artery performator flaps with cervicoplasty. Plast Reconstr Surg. 2007;120(6);1524-32.

Persichetti P, Francesco-Marangi G, Giglioflorito P, et al. Myocapsular pectoralis major flap for pharyngeal reconstruction after cervical necrotizing fasciitis. Plast Reconstr Surg.
2010;125(5):208e-210e.

Ramirez P, Leibowitz A, Traylor-Knowles M, et al. Short-flap facelift with 924 nm/975 nm laser lipolysis: a retrospective study of 78 patients. J Cosmet Dermatol. 2014; 13(1):22-29.

Renukaswamy GM, Soma MA, Hartley BE. Midline cervical cleft: A rare congenital anomaly. Ann Otol Rhinol Laryngol. 2009;118(11):786-90.

Sabiston DC, Lyerly HK. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 17th ed. Philadelphia, PA: WB Saunders Co; 2004: 2199-200.

Sanan A, Most S. Rhytidectomy (Face-lift Surgery). JAMA. 2018 Dec; 320(22):2387. Available at: https://www.jamanetwork/journals/jama/fularticle/2718070. Accessed August 16, 2019.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

15819, 15825, 15826, 15828, 15829, 15838, 15839, 15876


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

MA11.075a
11/06/2019The policy has been reviewed and reissued to communicate the Company's continuing position on Rhytidectomy and/or Cervicoplasty With or Without Liposuction and/or Platysmaplasty.


MA11.075a
08/29/2018This policy has been reissued in accordance with the Company's annual review process.
05/19/2017This version of the policy will become effective 05/19/2017

The policy has been reviewed and updated to communicate the Company’s continuing position on rhytidectomy and/or cervicoplasty with or without liposuction and/or platysmaplasty.

MA11.075
12/07/2016This policy was reviewed and reissued in accordance with the Company's Policy Confirmation Review track. The references were updated accordingly. The policy was updated to be consistent with current template wording and format. The adoptable source for this policy is Consultant Review
09/16/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on Rhytidectomy and/or Cervicoplasty With or Without Liposuction and/or Platysmaplasty
01/01/2015This is a new policy.






Version Effective Date: 05/19/2017
Version Issued Date: 05/19/2017
Version Reissued Date: 11/06/2019