Medical Policy: 10.01.02
Original Effective Date: January 1994
Reviewed: September 2014
Revised: April 2009
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy 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 will be reviewed regularly and be updated as scientific
and medical literature becomes available.
The definition of reconstructive services may be based upon the etiology of the defect and whether the service is primarily indicated to improve or correct a functional impairment or is primarily to improve appearance. Cosmetic services are usually considered to be those that are primarily to restore appearance and that otherwise do not meet the definition of reconstructive or whose etiology is exempted from the definition of cosmetic. The presence or absence of a functional impairment is a critical point in interpreting coverage eligibility.
Determination of whether a proposed therapy would be considered reconstructive or cosmetic is interpreted in the context of the specific contract language. A service would be considered to be cosmetic in the absence of a functional impairment. Functional impairment could be defined as:
- a loss of functional capacity (Functional capacity is the ability or capability of an organ or system to perform its specified function)
- difficulties that substantially interfere with or limit role functioning in one or more major life activities including the following:
- Basic daily living skills (e.g., eating, bathing, dressing);
- Instrumental living skills (e.g., maintaining a household, managing money, getting around the community, taking prescribed medication); and
- Functioning in social, family, and vocational/educational contexts
In accordance with the Women's Health and Cancer Rights Act of 1998, in patients with breast cancer or a history of breast cancer, all reconstruction of the breast on which a mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses and treatment of complications of the mastectomy, including lymphedema are considered medically necessary and not subject to prior approval. This mandate includes breast disease beyond cancer that medically requires mastectomy for treatment and/or reconstruction (e.g., severe fibrocystic breast disease).
Services considered cosmetic and excluded from coverage, include, but are not limited to:
- Ear piercing
- Excision or correction of glabella frown lines
- Excision or treatment of decorative tattoos
- Complications of a non-covered cosmetic or reconstructive surgery
- Spider telangiectasia of the lower extremities
- Surgical removal or reformation of redundant skin and/or adipose tissue
- Breast augmentation except when provided in association with post-mastectomy reconstruction
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
- Administrative determinations based on contract benefits.
Date Reason Action
October 2010 Annual review Policy renewed
May 2011 Interim review Policy renewed
November 2011 Annual review Policy renewed
November 2012 Annual review Policy renewed
October 2013 Annual review Policy renewed
September 2014 Annual review Policy renewed
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.