Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Cosmetic Procedures
Policy #:MA12.009

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.

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.


POTENTIALLY COSMETIC PROCEDURES

Services that are determined to be cosmetic, following medical necessity review, are not covered by the Company because cosmetic services are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration. The following are services that may be considered cosmetic (this list is subject to change):
  • Blepharoplasty
  • Body contouring procedures (e.g., liposuction, lipectomy)
  • Botox injections
  • Calf implantation
  • Collagen injections
  • Cervicoplasty/platysmaplasty
  • Chin augmentation (genioplasty, mentoplasty)
  • Chemical peels
  • Cricothyroid approximation
  • Correction of diastasis recti abdominis
  • Dermabrasions/chemical peels
  • Excision of redundant skin
  • Facial masculinizing/feminizing surgeries (e.g., facial bone reduction)
  • Forehead reduction
  • Gluteal augmentation (e.g., silicone implants, fat transfer, fat grafting)
  • Gynecomastia surgery
  • Hair reconstruction (e.g. hair removal/electrolysis, hair transplantation, wigs)
  • Injectable dermal fillers (e.g., Sculptra, Radiesse)
  • Labiaplasty
  • Laryngoplasty
  • Lip reduction/enhancement
  • Orthognathic procedures
  • Otoplasty
  • Panniculectomy
  • Pectoral implantation
  • Pulsed-dye laser treatment
  • Reduction mammoplasty
  • Rhinoplasty
  • Rhytidectomy
  • Scar revision
  • Septoplasty
  • Trachea shave/reduction thyroid chondroplasty
  • Treatment of telangiectasia (spider veins), varicose veins
  • Tattooing (non therapeutic)
  • Voice modification surgery

Note: For services performed to revise the outcome of a previous cosmetic procedure are considered cosmetic and, therefore, a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

ALWAYS COSMETIC PROCEDURES

The following are not covered by the Company because they are always considered cosmetic services. Services that are considered cosmetic are not covered by the Company because cosmetic services are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration (this list is subject to change):
  • Abdominoplasty
  • Deoxycholic acid (Kybella™)

Note: For services performed to revise the outcome of a previous cosmetic procedure are considered cosmetic and, therefore, a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

CONDITIONS THAT MAY BE CONSIDERED MEDICALLY NECESSARY

The treatment of medical and surgical complications resulting from cosmetic procedures is considered medically necessary and, therefore covered when, if left untreated, the complications would endanger the health of the individual. Treatment is covered and eligible for reimbursement consideration by the Company based on the medical necessity for acute conditions such as, but not limited to:
  • Deep vein thrombosis
  • Hemorrhage
  • Incisional hernia
  • Infection
  • Myocardial infarction
  • Wound dehiscence

Services performed due to a condition resulting from an accident or where a functional impairment which results from a covered disease, injury or congenital birth defect may be considered medically necessary and, therefore, covered.

For medically necessary criteria for non-cosmetic uses of a potentially cosmetic procedure, specific Company policies may exist; please refer to such individual policies for criteria that address cosmetic services.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination.

BENEFIT APPLICATION

Services that are cosmetic are excluded for the Company’s Medicare Advantage products because they are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

FINANCIAL RESPONSIBILITY

Members are financially responsible for all costs associated with all cosmetic procedures.

Description

COSMETIC PROCEDURES

Cosmetic procedures 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.
References

American Academy of Dermatology and AAD Association. Position statement on the definitions of cosmetic and reconstructive Surgery. [AAD Web site]. 08/07/2010. Available at:
https://www.aad.org/forms/policies/uploads/ps/ps-definitions%20of%20cosmetic%20%20reconstructive%20surgery.pdf. Accessed April 22, 2019.

American Academy of Otolaryngology— Head and Neck Surgery. Facial plastic surgery. Patient health information. [ENT Web site]. 2019. Available at:http://www.entnet.org/content/facial-plastic-surgery-0 Accessed April 22, 2019.

American Board of Cosmetic Surgery. Cosmetic surgery vs. plastic surgery. [American Board of Cosmetic Surgery Web site]. 2019. Available at:
http://www.americanboardcosmeticsurgery.org/patient-resources/cosmetic-surgery-vs-plastic-surgery/ Accessed April 22, 2019.

Centers for Medicare & Medicaid Services (CMS). Department of Health and Human Services. Items and services that are not covered under the Medicare program. [CMS Web site]. August 2018. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Items-and-Services-Not-Covered-Under-Medicare-Booklet-ICN906765.pdf Accessed April 22, 2019.

Centers for Medicare & Medicaid Services (CMS). Billing and Coding Guidelines for Cosmetic and Reconstructive Surgery LCD. [CMS Web site]. 01/01/17. Available at:
https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/34698_20/L34698_GSURG032_BCG.pdf Accessed April 22, 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare benefit policy manual. Chapter 16 General exclusion from coverage. [CMS Web site]. 11/06/14. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c16.pdf Accessed April 22, 2019.

Evidence of Coverage.

Novitas Solutions. Local Coverage Determination (L35090). Cosmetic and Reconstructive Surgery. [Novitas Solutions Website]: Original 10/01/2015 (Revised: 04/04/2017). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35090&ver=36&DocID=L35090&bc=gAAAABAAAAAA&. Accessed April 22, 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)

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 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


Cross References

 Policy: MA05.021a:Injectable Dermal Fillers

 Policy: MA07.056d:Photodynamic Therapy (PDT) Using Levulan® Kerastick® or Ameluz® (Aminolevulinic Acid HCl [ALA])

 Policy: MA08.017e:Botulinum Toxin Agents

 Policy: MA11.001i:Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence

 Policy: MA11.030e:Reconstructive Breast Surgery

 Policy: MA11.046b:Hair Transplants and Cranial Prostheses (Wigs)

 Policy: MA11.047c:Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy

 Policy: MA11.050:Treatment of Medical and Surgical Complications

 Policy: MA11.058a:Otoplasty Otoplasty or Non-Surgical External Ear Molding

 Policy: MA11.067d:Labiaplasty

 Policy: MA11.070a:Lipectomy and Liposuction

 Policy: MA11.071a:Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)

 Policy: MA11.072:Application and Removal of Tattoos

 Policy: MA11.073c:Panniculectomy, Abdominoplasty, Abdominal Lipectomy, and Other Excisions of Redundant Skin

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

 Policy: MA11.076d:Removal of Breast Implants

 Policy: MA11.078b:Scar Revision

 Policy: MA11.080a:Mentoplasty or Genioplasty

 Policy: MA11.083a:Orthognathic Surgery

 Policy: MA11.099a:Septoplasty, Rhinoplasty, and Septorhinoplasty

 Policy: MA11.103a:Chemical Peels

 Policy: MA11.109a:Procedures for the Treatment of Acne

 Policy: MA11.110:Surgery for Gynecomastia




Policy History

MA12.009
05/22/2019The policy has been reviewed and reissued to communicate the Company's continuing position on Cosmetic Procedures
10/24/2018This policy has been reissued in accordance with the Company's annual review process.
07/01/2017This version of the policy will become effective 07/01/2017.

The following new policy has been developed to communicate the Company's continuing position on cosmetic and potentially cosmetic procedures.






Version Effective Date: 07/01/2017
Version Issued Date: 07/01/2017
Version Reissued Date: 05/22/2019