Cosmetic/Reconstructive Services

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» Description» Selected References
» Prior Approval» Policy History
» Policy
 

Medical Policy: 10.01.02 
Original Effective Date: January 1994 
Reviewed: September 2014 
Revised: April 2009 


Benefit Application
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.


Description: 

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.


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Prior Approval: 

 

Not applicable


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Policy: 

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
  • Liposuction
  • Lipectomy
  • 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
  • Otoplasty
  • Surgical removal or reformation of redundant skin and/or adipose tissue
  • Breast augmentation except when provided in association with post-mastectomy reconstruction 

 

 





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Procedure Codes and Billing Guidelines: 

  • To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.

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Selected References: 

  • Administrative determinations based on contract benefits.

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Policy History: 

 

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


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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.

Contact Information
New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
  Wellmark Blue Cross and Blue Shield
  Medical Policy Analyst
  P.O. Box 9232
  Des Moines, IA 50306-9232
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Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association doing business in Iowa and South Dakota.
 
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