Medical Policy: 10.01.02
Original Effective Date: January 1994
Reviewed: May 2018
Revised: May 2017
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 as the result of an illness, injury or birth defect or it is primarily to improve appearance. Cosmetic services are usually considered to be those that primarily improve or alter an individual's appearance, self-esteem, where functional impairment is not present 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 service 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:
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).
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
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.