Medical Policy: 10.01.02
Original Effective Date: January 1994
Reviewed: January 2021
Revised: January 2021
This policy contains information which is clinical in nature. The policy is not medical advice. The information in this policy is used by Wellmark to make determinations whether medical treatment is covered under the terms of a Wellmark member's health benefit plan. Physicians and other health care providers are responsible for medical advice and treatment. If you have specific health care needs, you should consult an appropriate health care professional. If you would like to request an accessible version of this document, please contact customer service at 800-524-9242.
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.
There are generally two types of plastic surgery, cosmetic and reconstructive. Cosmetic surgery is performed to improve appearance, not to improve function or ability. Cosmetic surgery is considered a non-covered benefit. Reconstructive surgery focuses on reconstructing defects of the body or face due to congenital defects, trauma, infection, tumors or disease. Reconstructive surgery is designed to restore or improve function associated with the presence of a defect but may also be performed to achieve a more typical appearance of the affected structure.
The presence or absence of a functional impairment is a critical point in interpreting coverage eligibility. Functional impairment is defined as the following:
While reconstructive is often taken to mean that the service “returns the patient to whole” and cosmetic is often interpreted as meaning the restoration of appearance only, the application of these terms must be based on the specific contract language, refer to the member’s benefit document.
Cosmetic plastic surgery includes surgical and nonsurgical procedures that enhance and reshape structures of the body to improve appearance and confidence. Plastic surgery is a personal choice and should be done for yourself, not to meet someone else’s expectations or to try to fit an ideal image. Because it is elective, cosmetic surgery is usually not covered by health insurance.
Procedure | Description |
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Breast | |
Breast Augmentation (Augmentation Mammoplasty) | Involves using breast implants or fat transfer to increase the size of the breasts. This procedure can restore breast volume lost after weight reduction or pregnancy, achieve a more rounded breast shape or improve natural breast size asymmetry (enhance self-image and self-confidence) |
Breast Implant Revision | The goal of breast implant revision surgery is to replace old breast implants with new implants. Often the goal is also to change or improve the appearance of the breasts while updating the implant material, which could include: a concurrent breast lift or reduction; reshaping the breast implant pocket to reposition the implant on the chest; either increasing or decreasing the size, shape, style of the breast implant |
Breast Implant Removal | The goal of breast implant removal surgery is to remove the breast implant from breast augmentation or breast reconstruction patients. During these procedures, the surgeon may also remove silicone material from implant leaks and the breast capsule, which is the scar tissue that forms after the placement of a breast implant |
Breast Reduction (Reduction Mammaplasty) | Is a procedure to remove excess breast fat, glandular tissue and skin to achieve a breast size more in proportion with the body and to alleviate the discomfort associated with excessively large breasts (macromastia). Although breast reduction is often performed to address medical issues, patients who do not have the symptoms of macromastia but are unhappy with the size of their breasts can still pursue breast reduction as an aesthetic procedure. Patients choosing to undergo breast reduction surgery for cosmetic reasons may cite any number of factors, including social stigmas and wardrobe concerns |
Breast Lift (Mastopexy) | Raises the breasts by removing excess skin and tightening the surrounding tissue to reshape and support the new breast contour. A breast lift can rejuvenate the figure with a breast profile that is more youthful and uplifted. A woman’s breasts often change over time, losing their youthful shape and firmness. These changes and loss of skin elasticity can result from: pregnancy, breastfeeding, weight fluctuations, aging, gravity and heredity |
Fat Transfer Breast Augmentation (Breast Augmentation with Fat, Grafting) | Essentially uses liposuction to take fat from other parts of the body and inject into the breasts. This is a breast augmentation option for women who are looking for a relatively small increase in breast size and would prefer natural results |
Fat Reduction | |
Liposuction (Lipoplasty) | Liposuction is sometimes referred to as “lipo” by patients, it slims and reshapes specific areas of the body by removing excess fat deposits and improving body contours and proportion of the following areas: thighs; hips and buttocks; abdomen and waist; upper arms; back; inner knee; chest area; cheeks, chin and neck; calves and ankles. Liposuction can be performed alone or along with other plastic surgery procedures, such as facelift, breast reduction or a tummy tuck |
Liposuction – Assisted (Laser/Ultrasound Assisted) | Liposuction assisted with laser or ultrasound liquifies the fat before it is removed from the body. Like traditional liposuction, this is not a weight control method or fix for obesity. This is used to help contour the body in those areas that are not responsive to diet and exercise such as saddlebags and paunchy stomach. Also, like traditional liposuction, laser or ultrasound assisted liposuction is most often used to reduce fullness in the following areas: abdomen; ankles; arms; buttocks; cheeks; chin; hips; knees; neck; thighs; upper arms; waist |
Nonsurgical fat reduction (minimally invasive procedures) |
Nonsurgical or minimally invasive options for fat reduction include technology that uses heat, cooling or an injected medication to reduce fat cells. While none of these treatments are a replacement for liposuction, they provide options for patients unwilling or unable to undergo surgery. Nonsurgical fat reduction options use a variety of modalities, including ultrasound, radiofrequency, infrared light, vacuum massage and injectable medication Among the procedures that comprise nonsurgical fat reduction are:
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Body Lifts | |
Arm Lift (Brachioplasty) | Reshapes the under portion of the upper arm, from the underarm region to the elbow. Reduces excess sagging skin that droops downward; tighten and smooths the underlying supportive tissue that defines the shape of the upper arm; and reduces localized pockets of fat in the upper arm region
Improves the shape and tone of the underlying tissue that supports fat and skin. Excess sagging fat and skin are also removed and the procedure(s) can improve a dimpled, irregular skin surface. A body lift may include these areas: abdominal area (locally or extending around the sides and into the lower back area); buttocks; thigh (the inner, outer, or posterior thigh, or the thigh’s circumference). In cases where skin elasticity is poor, body lift technique along with liposuction may be recommended |
Mommy Makeover |
The goal of a mommy makeover is to restore the shape and appearance of a woman’s body after childbearing. There are many areas of the body that can be addressed, most commonly the breasts, abdomen, waist, genitalia and buttocks. A mommy makeover is typically performed as a single stage procedure. There are many techniques used to perform a mommy makeover, and many factors should be taken into consideration when choosing which techniques are best:
Possible procedures in a mommy makeover:
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Tummy Tuck (Abdominoplasty) | A tummy tuck, also known as abdominoplasty, removes excess fat and skin and restores weakened muscles to create a smoother, firmer abdominal profile |
Body Contouring | Body contouring helps with skin removal after major weight loss. The surgery improves the tone of underlying tissue and removes excess fat and skin. Body contouring procedures may include the following: arm lift (correct sagging of the upper arms); breast lift (correct sagging, flattened breasts); facelift (correct sagging of the mid-face, jowls and neck); lower body lifts (correct sagging of the abdomen, buttocks, inner and outer thighs); medial thigh lift (correct sagging of the inner thigh); tummy tuck (correct apron of excess skin hanging over the abdomen) |
Buttock Enhancement (Gluteal Augmentation and Lift) | Is used to improve the contour, size and/or shape of the buttocks. This is done through the use of buttock implants, fat grafting or sometimes a combination of the two. Buttock implants are silicone-filled devices that are surgically placed deep within the tissues of the buttock. Buttock augmentation through the use of fat grafting involves the transfer of fat from one area of the body into tissues of the buttocks. This technique is sometimes referred to as a Brazilian Butt Lift |
Thigh Lift | Reshapes the thighs by reducing excess skin and fat, resulting in smoother skin and better proportioned contours of the thighs and lower body. In cases where skin elasticity is poor, a thigh lift along with liposuction may be recommended |
Face and Neck | |
Brow Lift (Forehead Lift) | A brow lift, also known as a forehead lift, reduces wrinkles, improves frown lines and places the eyebrows in a youthful position. Other cosmetic procedures that may be performed with a brow lift include the following: upper and or lower eyelid surgery (blepharoplasty); facelifting; skin resurfacing techniques |
Cheek Augmentation (Cheek Enhancement) | The goal of cheek augmentation is to add volume or life to the cheeks. Some people are bothered by their cheeks losing volume, or even sagging with age. Others never develop the desired volume in their cheeks and are bothered by cheeks that may be considered flat or thin. Valid surgical options for augmenting and enhancing the cheeks are fat grafting/transfer (where a patient’s one fat is used) or the use of solid cheek implants. A nonsurgical option is the use of injectable fillers (dermal fillers) to enhance the cheeks |
Ear Surgery (Otoplasty) | Ear surgery, also known as otoplasty, improves the shape, position and proportion of the ear |
Facelift Surgery (Rhytidectomy) | A facelift, or rhytidectomy, is a surgical procedure to improve visible signs of aging in the face and neck. Other procedures that might be performed in conjunction with a facelift are brow lift and eyelid surgery to rejuvenate aging eyes. Fat transfers or fillers may be suggested to replace the lost fatty volume |
Neck Lift (Lower Rhytidectomy) | A neck lift, or lower rhytidectomy, is a surgical procedure that improves visible signs of aging in the jawline and neck. Rejuvenation procedures that can be performed in conjunction with a neck lift are the following: a brow lift (correct a sagging or deeply furrowed brow); fat transfer (to add fullness to the lips and cheeks and reduce the appearance or wrinkles); or eyelid surgery to rejuvenate aging eyes |
Buccal Fat Removal (Cheek Reduction) | The goal of buccal fat removal is to thin the cheeks, specifically in the area of the cheek hollows |
Chin Surgery (Mentoplasty) |
Chin surgery, or mentoplasty, is a surgical procedure to reshape the chin either by enhancement with an implant or reduction surgery on the bone. Sometime bone from the jaw itself can be moved forward in an operation called mentoplasty or genioplasty. Alternatively, shaped silicone implants can be used to give more projection to the chin. Conversely, bone can be removed to decrease an overly projecting chin A plastic surgeon may recommend chin surgery or procedures to a patient having a rhinoplasty in order to achieve better facial proportions, as the size of the chin may magnify or minimize the perceived size of the nose |
Eyelid Surgery (Blepharoplasty) | Eyelid surgery, or blepharoplasty, is a surgical procedure to improve the appearance of the eyelids. Surgery can be performed on the upper lids, lower lids or both |
Facial Implants | Facial implants are used to bring balance to the appearance of the face. These implants are commonly used to enhance the chin, jaw and/or cheeks. Facial implants are specially formed solid materials compatible with human tissues, designed to enhance or augment the physical structure of the face |
Rhinoplasty (Nose Surgery) | Rhinoplasty, sometimes referred to as a “nose job” by patients enhances facial harmony and the proportions of the nose. It can also correct impaired breathing caused by structural defects in the nose |
Minimally Invasive | |
Botulinum Toxin (Botox, Dysport, Xeomin, Jeuveau) | The cosmetic form of botulinum toxin is a popular injectable that temporarily reduces or eliminates facial fine lines and wrinkles. The most commonly treated areas are frown lines, forehead creases, crow’s feet near the eyes. Several other areas have been treated such as thick bands in the neck, thick jaw muscles, lip lines and gummy smiles |
Dermabrasion | Is often used to improve the look of facial and skin left scarred by accidents or previous surgery, or to smooth out facial wrinkles. Dermabrasion and dermaplaning help to “refinish” the skin’s top layers through a method of controlled surgical scraping. The treatments soften the sharp edges of surface irregularities, give the skin a smoother appearance. They can be used alone or in conjunction with other procedures such as facelift, scare removal/revision or chemical peel
Is a noninvasive technique that uses highly concentrated light to penetrate hair follicles and inhibit future hair growth. Because laser hair removal only affects actively growing hair follicles, it may take several laser hair removal treatments to provide significant hair reduction. Periodic maintenance treatments may be needed |
Microdermabrasion | Uses a minimally abrasive instrument to gently sand the skin, removing the thicker, uneven outer layer. This is used to treat light scarring, discoloration, sun damage, and stretch marks. Microdermabrasion helps to thicken the collagen, which results in a younger looking complexion |
Spider Vein Treatment | The most common spider vein treatment involves the injection of solution into the affected vein, causing the vein to collapse and fade over time. Laser treatments are also available for the reduction or removal of spider veins |
Chemical Peel | Uses a chemical solution to smooth the texture of the skin by removing the damaged outer layer |
Dermal Fillers | Injectable dermal fillers can plump up thin lips, enhance shallow contours, soften facial creases, remove wrinkles and improve the appearance of scars |
Laser Skin Resurfacing | Also, known as laser peel, laser vaporization and lasabrasion, can reduce facial wrinkles, scars and blemishes. It’s all about using beams of light. The surgeon will use the laser to send short, concentrated pulsating beam of light at irregular skin. This removes unwanted, damaged skin in a very precise manner one layer at a time. The laser beam used in laser resurfacing will remove outer layer of skin, called the epidermis. It simultaneously heats the underlying skin, called the dermis. This action works to stimulate growth of new collagen fibers. As the treated area heals, the new skin that forms is smoother and firmer |
Skin Rejuvenation and Resurfacing |
Skin rejuvenation and resurfacing can be achieved in several ways; different treatment modalities are available to treat the different aspects of skin damage. The following are some examples of skin rejuvenation and resurfacing treatment methods:
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Tattoo Removal | Tattoo removal can be achieved in a number of ways, ranging from laser treatments, chemical peels, dermabrasion and surgical excision. |
Male-Specific Plastic Surgery | |
Gynecomastia Surgery (Male Breast Reduction Surgery) | Reduces breast size in men, flattening and enhancing the chest contours. Plastic surgery to correct gynecomastia is technically called reduction mammaplasty. Gynecomastia can cause emotional discomfort and impair self-confidence. Some men may even avoid certain physical activities and intimacy simply to hide their condition |
Men and Plastic Surgery (Male-Specific Considerations) | Plastic surgery for men has become increasingly popular over the years. Men are seeking a balanced nose, a rejuvenated face and trimmer waistline. The procedures used to achieve these goals must take into consideration factors such as skin thickness, beard growth or body type.
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Hair Transplant (Surgical Hair Replacement) |
Hair transplant surgery is performed to restore hair to areas of the scalp that are bald or that having thinning hair. There are multiple types of hair replacement surgery. Most commonly, these involve hair transplantation, but flap surgery, tissue expansion of the scalp and scalp reduction surgery, are also methods used for hair replacement. Each of these types of surgeries can be used alone, or in combination, to provide the patient with the best possible outcome for hair replacement.
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Vaginal Rejuvenation | |
Nonsurgical Vaginal Rejuvenation | Nonsurgical vaginal rejuvenation can help to reverse changes in a women’s genitalia that are caused by childbearing, hormonal changes and/or aging. Changes that can impact a woman’s quality of life include vaginal laxity, stress urinary incontinence, loss of vaginal lubrication, a decrease in erotic sensation and loss of tone of the labia majora. Devices that have been developed to treat some or all these changes uses radiofrequency or laser energy to induce collagen tightening. Fillers are sometimes used to inject in the clitoris and/or “G-spot.” The field of nonsurgical female genital rejuvenation is growing as the change women experience receive greater attention |
Vaginal Rejuvenation (Surgical Options) | The term vaginal rejuvenation covers several different procedures, it is sometimes called female genital plastic surgery, female genital rejuvenation surgery, female genital cosmetic surgery, vulvovaginal plastic surgery and designer vagina surgery, among other terms. Among the procedures that comprise female genital plastic surgery are labiaplasty, clitoral hood reduction, labia majoraplasty, monsplasty and vaginoplasty |
Reconstructive surgery is performed to treat structures of the body affected aesthetically or functionally by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally done to improve function and ability but may also be performed to achieve a more typical appearance of the affected structure. Reconstructive surgery is generally covered by most health insurance policies, although coverage for specific procedures and levels of coverage may vary greatly.
Procedure | Description |
---|---|
Breast Implant Removal | The goal of breast implant removal surgery is to remove breast implants from breast augmentation or breast reconstruction patients. During these procedures, the surgeon may also remove silicone material from implant leaks and the breast capsule, which is the scar tissue that forms after the placement of a breast implant |
Breast Reconstruction |
The goal of breast reconstruction is to restore one or both breasts to near normal shape, appearance, symmetry and size following mastectomy, lumpectomy or congenital deformities. Breast reconstruction often involves multiple procedures performed in stages and can either begin at the time of mastectomy or be delayed until a later date. Breast reconstruction generally falls into two categories:
|
Breast Reduction (Reduction Mammaplasty) |
Is a procedure to remove excess breast fat, glandular tissue and skin to achieve a breast size more in proportion with the individual’s body and to alleviate the discomfort associated with excessively large breasts (macromastia). Patients with macromastia may experience physical discomfort resulting from the weight of their breasts. The resulting pain can make it challenging for some patients to perform common physical activities. Although breast reduction is often performed to address medical issues, patients who do not have the symptoms of macromastia but are unhappy with the size of their breasts can still pursue reduction as an aesthetic procedure. Patients choosing to undergo breast reduction surgery for cosmetic reasons may cite any number of factors, including social stigmas and wardrobe concerns. |
Cleft Lip and Palate Repair | Cleft lip and cleft palate are among the most common birth anomalies affecting children. The incomplete formation of the upper lip (cleft lip) or roof of the mouth (cleft palate) can occur individually, or both defects may occur together. The conditions can vary in severity and may involve one or both sides of the mouth. Surgery is required to repair cleft lip and/or cleft palate
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Craniosynostosis Surgery (Head Reshaping) | Craniosynostosis is a condition in which the fibrous joints between the skull bones fuse too early. These joints are known as sutures. If this occurs (usually before or at birth) it can cause an abnormal head shape, or in some cases restrict growth of the brain, which increases the pressure inside the skull. Surgery for craniosynostosis is designed to correct the abnormal head shape and allow the growing brain room to expand normally
The surgery for craniosynostosis is typically performed in the first two years of life. There are multiple types of surgery used to treat craniosynostosis, including strip craniectomy, spring-assisted craniectomy and cranial vault remodeling, amongst others. The surgery is performed by a team of a plastic surgeon and a neurosurgeon, working together |
Giant Nevi Removal | Children can be born with pigmented moles called congenital nevi (or nevus, if singular). These represent a proliferation of melanocytes, the pigment- producing cells of the skin. When they occur, congenital melanocytic nevi can be highly varied in size and shape. They may be very small and insignificant in appearance to very bit, covering large areas of the body. Small congenital nevi are those less than 1.5 cm in size. Giant nevi are those measuring 20 cm or more in size at birth. The goal of giant nevi removal surgery is to remove the mole in its entirety or at least as much as possible
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Hand Surgery | Hand surgery seeks to restore the normal function of fingers and hands injured by trauma or to correct abnormalities that were present at birth. |
Panniculectomy | The goal of panniculectomy surgery is to remove hanging skin and fat from the lower abdomen to create a smoother abdominal contour. A panniculectomy differs from a tummy tuck in that the abdominal muscles are typically not tightened during a panniculectomy |
Scar Revision Surgery | Scar revision surgery will attempt to minimize a scar so that it is less conspicuous and blends in with the surrounding skin tone and texture. Scars are visible signs that remain after a wound has healed. They are the unavoidable results of injury or surgery, and their development can be unpredictable. Poor healing may contribute to scars that are obvious, unsightly or disfiguring. Even a wound that heals well can result in scar that effects appearance. Scars may be noticeable due to their size, shape or location; they can also be raised or depressed and may differ in color or texture from the surrounding healthy tissue. Treatment options vary based on the type and degree of scarring and can include:
Although scar revision can provide a more pleasing cosmetic result or improve a scar that has healed poorly, a scar cannot be completely erased. Scar revision is plastic surgery performed to improve the condition or appearance of a scar anywhere on the body. The different types of scars include:
The type of scar will determine the appropriate techniques used by the plastic surgeon to improve the scar |
Septoplasty (Deviated Septum Correction) | Is a surgical procedure performed to correct a deviated septum, the septum is a wall of bone and cartilage, which separates the two nostrils. A deviated septum or “crooked” septum occurs when the septum is shifted towards one side of the nasal cavity. This can cause difficult breathing and reduced airflow due to blockage of the nasal airway. During septoplasty surgery, the septum is straightened and repositioned to the middle of the nose. This procedure may include cutting and removing parts of the septum before reinserting them into the correction position. A septoplasty can be performed by itself or often it can be combined with a rhinoplasty. |
Skin Cancer Removal (Reconstruction after Skin Cancer) | Skin cancer may require surgical removal of the cancerous growth. A plastic surgeon can surgically remove cancerous and other skin lesions using specialized techniques to preserve appearance. Although no surgery is without scars, the plastic surgeon will make every effort to treat skin cancer without dramatically changing the individual’s appearance. |
Tissue Expansion | Tissue expansion is a relatively straightforward procedure that enable the body to “grow” extra skin for use in reconstructing almost any part of the body. A silicone balloon expander is inserted under the skin near the area to be repaired and then gradually filled with saline or carbon dioxide over time, causing the skin to stretch and grow. It is most commonly used for breast reconstruction following breast removal, but it’s also used to repair skin damaged by birth defects, accidents, surgery and in certain cosmetic procedures. |
In 2007 (reaffirmed 2019), ACOG issued a Committee Opinion (number 378) regarding vaginal "rejuvenation" and cosmetic vaginal procedures that states: "So-called “vaginal rejuvenation," "revirgination", and "G-spot amplification" are vaginal surgical procedures being offered by some practitioners. These procedures are not medically indicated, and the safety and effectiveness of these procedures have not been documented. Clinicians who receive requests from patients for such procedures should discuss with the patient the reason for her request and perform an evaluation for any physical signs or symptoms that may indicate the need for surgical intervention. Women should be informed about the lack of data supporting the efficacy of these procedures and the potential complications, including infection, altered sensation, dyspareunia, adhesions, and scarring.” No adequate studies have been published assessing the long-term satisfaction, safety and complication rates of these procedures.
Not required
Determination of whether a proposed service would be considered reconstructive or cosmetic is interpreted in the context of the specific contract language. Refer to the member's benefit document. Also, refer to Policy Guideline section below for additional information.
A procedure will be considered reconstructive and medically necessary when the primary purpose is to improve or restore function of a physical functional impairment of an abnormal body function when performed for any of the following, even if there is an incidental improvement in physical appearance:
The documentation requirements outlined below are used to assess whether the member meets the clinical criteria for coverage and does not guarantee coverage of the service requested, submit medical notes documenting ALL of the following:
Covered breast reconstruction following mastectomy includes 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.
A procedure/service, or drug(s) are considered COSMETIC when performed primarily to enhance or otherwise alter physical appearance without an expectation of correcting or improving a functional impairment and are excluded from coverage and considered a non-covered benefit. Procedure/service and drug(s) considered COSMETIC include, but are not limited to the following:
A procedure/service, or drug(s) are considered COSMETIC when performed primarily to enhance or otherwise alter physical appearance without an expectation of correcting or improving a functional impairment and are excluded from coverage. Therefore, the following drug(s)/biologics are considered COSMETIC and excluded from coverage (not an all-inclusive list):
• Botox Cosmetic (onabotulinum toxin for cosmetic use)
The final determination of eligibility of coverage should be based on application of the individual’s specific contract language based on the etiology of the defect and the presence or absence of documented functional impairment (see definitions below).
The following general principles describe the issues to be determined in properly administering contract language:
Considerations when reviewing a case: Contract language may vary regarding the definition of reconstructive services for different categories of conditions: Key considerations are listed below:
Accidental Injury: An injury, independent of disease or bodily infirmity or any other cause, that happens by chance and requires immediate medical attention.
Adjacent Tissue Transfer: A random pattern local flap which is used to fill in nearby or local defect. To be considered an adjacent tissue transfer an incision must be made by the surgeon which results in a secondary defect. Examples include: transposition flaps; advancement flaps and rotation flaps.
Aesthetic: Aimed at improving the physical appearance and satisfaction of the patient.
Complications of a Noncovered Services: A member is not covered for a complication resulting from a noncovered service, supply, device or drug. However, this exclusion does not apply to the treatment of complications resulting from:
Congenital Anomaly (i.e. Birth Defect): A physical developmental defect that is present at the time of birth or is identified within the first twelve months of the birth.
The World Health Organization (WHO) defines Congenital Anomalies as the following: Congenital anomalies are also known as birth defects, congenital disorders or congenital malformation. Congenital anomalies can be defined as structural or functional anomalies that occur during intrauterine life and can be identified prenatally, at birth or sometimes may only be detected later in infancy.
Cosmetic Services: (Not Covered): Cosmetic Services, supplies, or drugs if provided primarily to improve physical appearance. A service, supply or drug that results in an incidental improvement in appearance may be covered if it is provided primarily to restore function lost or impaired as the result of an illness, accidental injury, or a birth defect. Treatment for any complications resulting from a noncovered cosmetic procedure are also not covered.
The American Society of Plastic Surgeons defines Cosmetic Procedures as the following: Cosmetic plastic surgery includes surgical and nonsurgical procedures that enhance and reshape structures of the body to improve appearance and confidence.
Drugs, Services and Items that are Not Covered: Drugs, services and items that are not covered under your prescription drug benefits include but are not limited to: Cosmetic drugs.
Functional Impairment: A functional impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions or perform physical activities and is exhibited by difficulties in one or more of the following areas: physical and motor tasks; independent movement; performing basic life functions (e.g. eating, bathing, dressing).
Illness or Injury Services: Any bodily disorder, bodily injury, disease, or mental health condition, including pregnancy and complications of pregnancy.
Reconstructive Surgery: Reconstructive surgery primarily intended to restore function lost or impaired as a result of an illness, injury or birth defect (even if there is incidental improvement in physical appearance) including breast reconstructive surgery following mastectomy. Breast reconstructive surgery includes the following:
The American Society of Plastic Surgeons defines Reconstructive Procedures as the following: Reconstructive surgery is performed to treat structures of the body affected aesthetically or functionally by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. Reconstructive surgery is generally done to improve function and ability but may also be performed to achieve a more typical appearance of the affected structure.
Prosthetic Devices: Devices used as artificial substitutes to replace a missing natural part of the body or to improve, aid, or increase the performance of a natural function.
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
The following list(s) of procedure codes is provided for reference purposes only and may not be all inclusive. Listing of a code does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Coverage Determination Guidelines may apply.
The following codes are considered cosmetic; these codes do not improve a functional impairment
CPT Code | Description |
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11950 | Subcutaneous injection of filling material (e.g., collagen); 1 cc or less |
11951 | Subcutaneous injection of filling material (e.g., collagen); 1.1 to 5.0 cc |
11952 | Subcutaneous injection of filling material (e.g., collagen); 5.1 to 10.0 cc |
11954 |
Subcutaneous injection of filling material (e.g., collagen); over 10.0 cc |
15775 | Punch graft for hair transplant; 1 to 15 punch grafts |
15776 | Punch graft for hair transplant; more than 15 punch grafts |
15783 | Dermabrasion; superficial, any site (e.g., tattoo removal) |
15786 | Abrasion; single lesion (e.g., keratosis, scar) |
15787 | Abrasion; each additional 4 lesions or less (List separately in addition to code for primary procedure) |
15819 | Cervicoplasty |
15820 | Blepharoplasty, lower eyelid |
15821 | Blepharoplasty, lower eyelid; with extensive herniated fat pad |
15824 | Rhytidectomy; forehead |
15825 | Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) |
15826 | Rhytidectomy; glabellar frown lines |
15828 | Rhytidectomy; cheek, chin, and neck |
15829 | Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap |
15832 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh |
15833 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg |
15834 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip |
15835 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock |
15836 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm |
15837 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand |
15838 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad |
15839 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area |
15847 | Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) |
15876 | Suction assisted lipectomy; head and neck |
15877 | Suction assisted lipectomy; trunk |
15878 | Suction assisted lipectomy; upper extremity |
15879 | Suction assisted lipectomy; lower extremity |
17360 | Chemical exfoliation for acne (e.g. acne paste, acid) |
17380 | Electrolysis epilation, each 30 minutes |
19355 | Correction of inverted nipples |
36468 | Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk |
69090 | Ear piercing |
69300 | Otoplasty, protruding ear, with or without size reduction |
HCPCS | Description |
---|---|
G0429 | Dermal filler injection(s) for treatment of facial lipodystrophy syndrome (LDS) (e.g. as a result of highly active antiretroviral therapy) |
J0591 | Injection deoxycholic acid 1 mg (Kybella) |
J3490 | Unclassified drug – may be used for Egrifta; Botox Cosmetic (onabotulinum toxin for cosmetic use; Refer to the Neuromuscular Blocking Agents Drug Policy if requesting Botox for a medical condition); Juvederm; Latisse (bimatoprost); Vaniqa (elornithine); Any drug with an FDA approved indication that is only to preserve or improve appearance in the absence of a physical functional impairment |
J3590 | Unclassified biologics – may be used for Egrifta; Botox Cosmetic (onabotulinum toxin for cosmetic use; Refer to the Neuromuscular Blocking Agents Drug Policy if requesting Botox for a medical condition); Juvederm; Latisse (bimatoprost); Vaniqa (elornithine); Any drug with an FDA approved indication that is only to preserve or improve appearance in the absence of a physical functional impairment |
Q2026 | Injection, Radiesse, 0.1 ml |
Q2028 | Injection, Sculptra, 0.5 mg |
The following list of codes represents services that are considered cosmetic, these services do not improve a functional impairment, but lack a specific CPT or HCPCS code. The intent of this policy is to provide direction for the specific cosmetic services listed below.
Because unlisted codes can be reported with many services, the unlisted codes below may be reported for other services that may be considered a non-covered benefit, medically necessary or investigational when reported for other services. Please review the appropriate medical policy, if available, for the detailed coverage position involving the following unlisted codes.
CPT Code | Description |
---|---|
17999 | Unlisted procedure skin, mucous membrane and subcutaneous tissue
Note: See above cosmetic procedure list regarding the following:
|
96999 | Unlisted special dermatological services or procedure
Note: See above cosmetic procedure list regarding the following:
|
The following list(s) of procedure codes is provided for reference purposes only and may not be all inclusive. Listing of a code does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Coverage Determination Guidelines may apply.
The following codes may be cosmetic; a review may be required to determine if the procedure is considered cosmetic or reconstructive and clinical information may be requested to complete this review, see Required Documentation above.
11920 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq. cm or less |
11921 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq. cm |
11922 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq. cm, or part thereof (List separately in addition to code for primary procedure) |
11970 | Replacement of tissue expander with permanent implant |
11971 | Removal of tissue expander(s) without insertion of implant |
15570 | Formation of direct or tubed pedicle, with or without transfer; trunk |
15600 | Delay of flap or sectioning of flap (division and inset); at trunk |
15769 | Grafting of autologous soft tissue, other harvested by direct excision (e.g. fat, dermis, fascia) |
15771 | Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms and/or legs 50 cc or less injectate |
15772 | Each additional 50 cc injectate or part thereof (list separately in addition to code for primary procedure) |
15773 | Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or fee 25 cc or less injectate |
15774 | Each additional 25 cc injectate or part thereof (list separately in addition code for primary procedure) |
15830 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy |
19300 | Mastectomy for gynecomastia |
19316 | Mastopexy |
19318 | Breast reduction |
19325 | Breast augmentation with implant |
19328 | Removal of intact breast implant |
19330 | Removal of ruptured implant, including implant contents (e.g. saline, silicone gel) |
19340 | Insertion of breast implant on same day of mastectomy (i.e. immediate) |
19342 | Insertion of replacement of breast implant on separate day from mastectomy |
19350 | Nipple/areola reconstruction |
19357 | Tissue expander placement in breast reconstruction, including subsequent expansion(s) |
19361 | Breast reconstruction; with latissimus dorsi flap |
19364 | Breast reconstruction; with free flap (eg. fTRAM, DIEP, SIEA, GAP flap) |
19367 | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap |
19368 | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging) |
19369 | Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap |
19370 | Revision of peri-implant capsule, breast, including capsulotomy, sapsulorrhaphy, and/or partial capsulectomy |
19371 | Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents |
19380 | Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-insert of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction) |
19396 | Preparation of moulage for custom breast implant |
21088 | Impression and custom preparation; facial prosthesis |
21120 | Genioplasty; augmentation (autograft, allograft, prosthetic material) |
21121 | Genioplasty; sliding osteotomy, single piece |
21122 | Genioplasty; sliding osteotomies, 2 or more osteotomies (e.g., wedge excision or bone wedge reversal for asymmetrical chin) |
21123 | Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) |
21125 | Augmentation, mandibular body or angle; prosthetic material |
21127 | Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) |
21137 | Reduction forehead; contouring only |
21138 | Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) |
21139 | Reduction forehead; contouring and setback of anterior frontal sinus wall |
21172 | Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts) |
21179 | Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material) |
21180 | Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts) |
21208 | Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) |
21209 | Osteoplasty, facial bones; reduction |
21230 | Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) |
21235 | Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) |
21255 | Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) |
21256 | Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (e.g., micro-ophthalmia) |
21260 | Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach |
21261 | Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and extracranial approach |
21263 | Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement |
21267 | Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach |
21268 | Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and extracranial approach |
21270 | Malar augmentation, prosthetic material |
21280 | Medial canthopexy (separate procedure) |
21282 | Lateral canthopexy |
21295 | Reduction of masseter muscle and bone (e.g., for treatment of benign masseteric hypertrophy); extraoral approach |
21296 | Reduction of masseter muscle and bone (e.g., for treatment of benign masseteric hypertrophy); intraoral approach |
30400 | Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip |
30410 | Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip |
30420 | Rhinoplasty, primary; including major septal repair |
30430 | Rhinoplasty, secondary; minor revision (small amount of nasal tip work) |
30435 | Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) |
30450 | Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) |
54360 | Plastic operation on penis to correct angulation |
56620 | Vulvectomy simple; partial |
56625 | Vulvectomy, complete |
56800 | Plastic repair of introitus |
56810 | Perineoplasty, repair of perineum, nonobstetrical (separate procedure) |
57291 | Construction of artificial vagina without graft |
57292 | Construction of artificial vagina with graft |
67900 | Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) |
67901 | Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) |
67902 | Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia) |
67903 | Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach |
67904 | Repair of blepharoptosis; (tarso) levator resection or advancement, external approach |
67906 | Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) |
67908 | Repair of blepharoptosis; conjunctivo-tarso-Muller’s muscle-levator resection (e.g., Fasanella-Servat type) |
67909 | Reduction of overcorrection of ptosis |
69110 | Excision external ear; partial, simple repair |
The following unlisted codes (lack a specific CPT or HCPCS code) may be cosmetic; a review may be required to determine if the procedure(s) are considered cosmetic or reconstructive. The intent of this policy is to provide direction for the specific cosmetic or reconstructive services that may apply when these unlisted codes are utilized. Clinical information may be requested to complete this review, see Required Documentation above.
Because unlisted codes can be reported with many services, the unlisted codes below may be reported for other services that may be considered a non-covered benefit, medically necessary or investigational when reported for other services. Please review the appropriate medical policy, if available, for the detailed coverage position involving the following unlisted codes:
CPT Code | Description |
---|---|
19499 | Unlisted procedure, breast |
58999 | Unlisted Procedure female genital system (non-obstetrical) |
69399 | Unlisted procedure external ear |
Administrative determinations based on contract benefits, refer to the member's benefit document.
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.
*CPT® is a registered trademark of the American Medical Association.