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Medical Policy: 10.01.02
Original Effective Date: January 1994
Reviewed: October 2007
Revised: July 2005
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
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.
Policy:
Determination of whether a proposed therapy would be considered reconstructive or cosmetic is interpreted in the context of the specific contract language.
Prior approval is recommended for any service which has the potential to be considered cosmetic. Please note there may be other Wellmark medical policies specific to a particular procedure. Submit a prior approval now.
Services considered cosmetic and excluded from coverage, include, but are not limited to:
- Sex re-assignment surgery
- 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
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Procedure Codes and Billing
Guidelines:
- To report provider services, use appropriate CPT** codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
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Selected References:
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Administrative determinations based on contract benefits.
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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
Station 304
636 Grand Ave
Des Moines, Iowa 50309
*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
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.
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