Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Rhytidectomy and/or Cervicoplasty With or Without Liposuction and/or Platysmaplasty

Policy #:11.08.13g

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

RHYTIDECTOMY

When performed as a cosmetic service, rhytidectomy is a benefit contract exclusion for all products of the Company and is 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 and/or platysmaplasty is a benefit contract exclusion for all products of the Company and is not eligible for reimbursement consideration. 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 a benefit contract exclusion for all products of the Company. 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 a specific benefit contract exclusion exists.

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

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, rhytidectomy and/or cervicoplasty are covered under the medical benefits of the Company's products when the medically necessity criteria listed in the medical policy are met.

Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

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.

Lifestyle Lift is a procedure that uses minimal incisions and local anesthesia in order to lift, remove, and re-drape the skin of the face and neck in order to create a more youthful appearance. Because there are minimal incisions, this procedure is reported to have less bruising and swelling, thus allowing for quicker postoperative return to work than more traditional cervicoplasty surgery.

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 Society of Plastic Surgeons (ASPS). Facelift. [ASPS Web site]. Available at: http://www.plasticsurgery.org/cosmetic-procedures/facelift.html. Accessed March 16, 2017.

Briggs RD. Rhytidectomy. Grand Rounds presentation [The University of Texas Medical Branch, Department of Otolaryngology Web site]. May 2003. Available at:http://www.utmb.edu/otoref/grnds/Rhytidectomy-2003-0521/Rhytidectomy-slides-2003-0521.pdf. Accessed March 16, 2017.

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] 10/23/2016. Available at:
https://www.uptodate.com/contents/botulinum-toxin-for-cosmetic-indications-treatment-of-specific-sites. [via subscription only]. Accessed March 17, 2017.

Kilpatrick JK, LaFerriere KA. Rhytidectomy, deep plane facelift. [eMedicine Web site]. 08/12/2015. Available at: http://emedicine.medscape.com/article/841704-overview. Accessed March 16, 2017.

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]. 07/21/2015. Available at: http://emedicine.medscape.com/article/1294486-overview. Accessed March 16, 2017.

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.





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, 15824, 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


Cross References


Policy History

Revisions from 11. 08.13g:
08/29/2018This policy has been reissued in accordance with the Company's annual review process.


Effective 10/05/2017 this policy has been updated to the new policy template format.'
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Version Effective Date: 05/19/2017
Version Issued Date: 05/19/2017
Version Reissued Date: 08/30/2018

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.