Medicare Advantage

Cosmetic Procedures
MA12.009a

Policy

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
  • Cervicoplasty/platysmaplasty
  • Chin augmentation (genioplasty, mentoplasty)
  • Chemical peels
  • Cricothyroid approximation
  • Collagen injections
  • Collagenase clostridium histolyticum injections​
  • 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: 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
  • Kybella (Deoxycholic acid)
  • Qwo (Collagenase clostridium histolyticum)
Note: 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 a functional impairment resulting 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

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.

Collagenase clostridium histolyticum is a combination of bacterial collagenases with multiple medical and cosmetic uses. It is marketed under brand names Xiaflex and Qwo, each of which serve distinct populations. Intended uses for Xiaflex include Peyronie's disease and Dupuytren's contracture; medical necessity criteria is detailed in a separate policy. Qwo is a prescription medication used to treat moderate-severe buttocks cellulite in adult women via subcutaneous injection. Specifically, Qwo enzymatically targets the fibrous connective tissue tethering the skin to the underlying fascia; disruption of these fibrous septae diminish the "dimpling" effect and lead to improved cellulite appearance. Although Qwo is the same pharmaceutical substance as Xiaflex, it is not indicated for treatment of Peyronie's disease or Dupuytren's contracture; it is approved solely for cosmetic usage. 

References

American Academy of Dermatology (AAD). Position statement on the definitions of cosmetic and reconstructive surgery. [AAD Web site]. 08/07/2010. Available at: https://server.aad.org/Forms/Policies/Uploads/PS/PS-Definitions of Cosmetic & Reconstructive Surgery.pdf. Accessed on October 2, 2020. 


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 October 2, 2020.

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 October 2, 2020.

Company Benefit Contracts.

 

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 October 2, 2020.

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 October 2, 2020.

Centers for Medicare & Medicaid Services (CMS). Medicare benefit policy manual. Chapter 16 General exclusion from coverage. [CMS Web site]. 11/6/14. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c16.pdf. Accessed October 2, 2020.

 

Endo Aesthetics LLC. Patient information: Qwo. [Endo Web site]. 07/2020. Available at: https://d1skd172ik98el.cloudfront.net/48a33315-f594-4269-8043-8853d10fb7bf/2be4acaf-4b1b-4b08-85ba-42a5befcec98/2be4acaf-4b1b-4b08-85ba-42a5befcec98_source__v.pdf. Accessed on October 1, 2020. 

 

Endo Aesthetics LLC. Qwo Web site. 07/2020. Available at: https://www.qwo.com/. Accessed on October 1, 2020. 

 

Endo International plc. 07/06/2020. Press release: U.S. FDA Approves Qwo™ (collagenase clostridium histolyticum-aaes), the first injectable treatment for cellulite. [Endo Web site]. Available at: https://investor.endo.com/news-releases/news-release-details/us-fda-approves-qwotm-collagenase-clostridium-histolyticum-aaes. Accessed on October 1, 2020. 

 

Food and Drug Administration (FDA). Prescribing information: Qwo. [FDA Web site]. 07/2020. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/761146s000lbl.pdf. Accessed on October 1, 2020. 


Novitas Solutions. Local Coverage Determination (L35090). Cosmetic and Reconstructive Surgery. [Novitas Solutions Website]: Original 10/01/2015 (Revised: 11/07/2019). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35090&ver=69&Date=&DocID=L35090&SearchType=Advanced&bc=EgAAAAIAAAAA&. Accessed October 2, 2020.​​


Coding

CPT Procedure Code Number(s)
N/A

ICD - 10 Procedure Code Number(s)
N/A

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

11/20/2020
11/20/2020
6/16/2021
MA12.009
Medical Policy Bulletin
Medicare Advantage
No