Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Cosmetic Procedures

Policy #:12.01.03

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 a member's contract.

POTENTIALLY COSMETIC PROCEDURES

Services that are determined to be cosmetic, following medical necessity review, are a benefit contract exclusion for all products of the Company. 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 and drugs that are cosmetic are a benefit contract exclusion for all products of the Company. 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.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, cosmetic procedures are a benefit contract exclusion for all Company products.

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 January 04, 2017.

American Academy of Otolaryngology— Head and Neck Surgery. Facial plastic surgery. Patient health information. [ENT Web site]. 2017. Available at:http://www.entnet.org/content/facial-plastic-surgery-0 Accessed January 04, 2017.

American Board of Cosmetic Surgery. Cosmetic surgery vs. plastic surgery. [American Board of Cosmetic Surgery Web site]. 2017. Available at:
http://www.americanboardcosmeticsurgery.org/patient-resources/cosmetic-surgery-vs-plastic-surgery/ Accessed January 04, 2017.

Benefit Contracts

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]. January 2015. 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 January 04, 2017.

Centers for Medicare & Medicaid Services (CMS). GSURG-032 Billing and Coding Guidelines for Cosmetic Services. [CMS Web site]. 11/15/2010. Available at:
https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/30733_1/l30733_gsurg032_cbg.pdf Accessed January 04, 2017.

Centers for Medicare & Medicaid Services (CMS). Medicare benefit policy manual. Chapter 16 General exclusion from coverage. [CMS Web site]. 10/01/03. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c16.pdf Accessed January 04, 2017.





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: 05.00.62h:Injectable Dermal Fillers

 Policy: 07.07.03l:Photodynamic Therapy (PDT) Using Levulan® Kerastick® (Aminolevulinic Acid HCl [ALA]) or Metvixia® (Methyl Aminolevulinate [MAL])

 Policy: 08.00.26u:Botulinum Toxin Agents

 Policy: 08.01.24:Deoxycholic Acid (Kybella™)

 Policy: 11.00.02f:Treatment of Medical and Surgical Complications

 Policy: 11.01.01j:Otoplasty or Non-Surgical External Ear Molding

 Policy: 11.02.01r:Treatment of Varicose Veins of the Lower Extremities and Perforator Vein Incompetence

 Policy: 11.05.02i:Blepharoplasty, Repair of Blepharoptosis, Repair of Brow Ptosis, and Canthoplasty/Canthopexy

 Policy: 11.06.09d:Labiaplasty

 Policy: 11.08.01f:Hair Transplants and Cranial Prostheses (Wigs)

 Policy: 11.08.02h:Reduction Mammoplasty

 Policy: 11.08.03j:Lipectomy and Liposuction

 Policy: 11.08.04h:Selective Photothermolysis Using Pulsed-Dye Lasers (PDL)

 Policy: 11.08.05g:Application and Removal of Tattoos

 Policy: 11.08.06j:Panniculectomy, Abdominoplasty, and Other Excisions of Redundant Skin

 Policy: 11.08.08g:Chemical Peels

 Policy: 11.08.12h:Surgery for Gynecomastia

 Policy: 11.08.13g:Rhytidectomy and/or Cervicoplasty With or Without Liposuction and/or Platysmaplasty

 Policy: 11.08.14j:Removal of Breast Implants

 Policy: 11.08.15u:Reconstructive Breast Surgery

 Policy: 11.08.25m:Scar Revision

 Policy: 11.08.29e:Procedures for the Treatment of Acne

 Policy: 11.14.01g:Mentoplasty or Genioplasty

 Policy: 11.14.08d:Orthognathic Surgery

 Policy: 11.16.01h:Septoplasty, Rhinoplasty, and Septorhinoplasty


Policy History

Revisions from 12.01.03:
10/24/2018This 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.


Version Effective Date: 07/01/2017
Version Issued Date: 06/30/2017
Version Reissued Date: 10/25/2018

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