Medical Policy: 10.01.02 

Original Effective Date: January 1994 

Reviewed: January 2021 

Revised: January 2021 

 

Notice:

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 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:

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:

  • A functional impairment 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 activities of daily living (e.g. eating, bathing, dressing).

 

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.  

 

Practice Guideline and Position Statements

American Society of Plastic Surgeons (ASPS)

Cosmetic Procedures

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.  

 

List of Cosmetic Procedures
Procedure Description
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:

  • Cryolipolysis (e.g. CoolSculpting)
  • Injection lipolysis (e.g. Kybella),
  • Radiofrequency lipolysis (e.g. Vanquish)
  • Laser lipolysis (e.g. SculpSure)   
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:

  • Desired amount of restoration
  • Placement of the incisions
  • Type of implant(s) used

Possible procedures in a mommy makeover:

  • Breast augmentation
  • Breast lift
  • Buttock augmentation
  • Liposuction
  • Tummy tuck
  • Vaginal rejuvenation
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:

  • Laser and Intense Pulse Light (IPL) Treatments: used to remove discoloration and/or tightening sagging skin
  • Chemical Peels: various acid peels used in different combinations to remove damaged outer skin layers
  • Ablative Laser Treatments (Fractional, CO2 Lasers): remove outer layers of skin to smooth lines and wrinkles
  • Mechanical Ablation (Dermabrasion, Dermaplaning): surgical scraping methods to soften skin surface irregularities
  • Non-Ablative Treatments (Microdermabrasion, Microneedling, Light Acid Peels): minimally invasive sanding methods to treat light scarring and discolorations
  • Dermal Fillers: injectable compounds to improve skin contouring
  • Botulinum Toxin Type A Treatments: blocks nerve contraction to relax wrinkles
  • Spider Vein Treatment: injections to collapse unsightly surface veins
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.
  • Men sometimes seek liposuction to remove fatty areas that are resistant to diet and exercise.
  • Abdomen reduction (a full abdominoplasty (tummy tuck) may be chose by men who have hanging abdominal skin (usually result of massive weight loss), loose abdominal muscles and/or neglected hernias. It is a major surgical procedure that removes excess fat, tightens the muscles of the abdominal wall and trims the waistline.   
  • Calf implants are used to create fullness in the lower leg. Similarly, pectoral implants which are used to build the chests of men with Poland’s syndrome, can also be used to “bulk out” the existing pectoral muscles of healthy men.
  • Abdominal etching, a new liposuction technique that creates a muscular, rippled appearance in the abdominal area
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.

  • Hair transplantation involves removing small pieces of hair-bearing scalp from a donor site and using them as grafts to be relocated to a bald or thinning area of the scalp
  • Flap surgeries involve moving hair bearing scalp tissue into bald areas of the scalp
  • Tissue expansion allows the hair bearing scalp to be expanded to help cover areas of the scalp that have no hair
  • Scalp reduction surgery involved surgically removing bald areas of the scalp and advancing, or bringing together, the hair bearing areas of the scalp
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 Procedures

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. 

 

List of Reconstructive Procedures
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:

  • Implant-based reconstruction: Relies on breast implants to help form a new breast mound
  • Flap (autologous) reconstruction: Uses the patient’s own tissue from another part of the body to form a new breast
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
  • Cleft lip repair and cleft palate repair are types of surgery used to correct this abnormal development and are meant to restore function to the lips and mouth along with producing a more normal appearance. Most clefts can be repaired through specialized plastic surgery techniques and will help improve the child’s ability to eat, speak, hear and breath.
  • Surgery to repair cleft of the lip or palate is highly individualized. Surgery is intended to close the cleft defect, but also help the child’s ability to function and grow normally. Cleft lip repair, also called cheiloplasty, includes reconstruction of the lip to create a more normal appearance, namely:
    • Closure of the cleft resulting in a scar located within or near the typical features of the upper lip
    • Formation of cupid’s bow (the curves along the center of the upper lip)
    • Establishing adequate distance between the upper lip and nose
  • Clefts of the upper lip typically affect the shape of the nose and additional procedures may be recommended to:
    • Restore nasal symmetry and nostril shape
    • Straighten and create adequate length for the columella (the tissue that separates the nostrils)
  • Because the palate creates the floor of the nasal cavity and is responsible for allowing normal speech, considerations in repairing cleft palate include:
    • Separating the mouth and nasal tissues by closing the defect along its length
    • Re-establishing soft palate muscle function to promote normal speech
    • Recreating normal relation of the soft palate to the auditory canal and Eustachian tube to allow normal hearing
    • Promoting as much as possible the normal growth and development of the upper jaw and teeth
    • Repairing when appropriate any defects in the gumline to allow for permanent tooth eruption.
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 
  • Rarely, some children born with giant congenital nevi are found to have deeper involvement of their tissues called neurocutaneous melanosis. The melanocytes involved in this condition proliferated in the brain and spinal cord early in fetal development and typically present with a giant scalp or trunk lesion and many smaller satellite lesions. These children can suffer from increased intracranial pressure, seizures or other neurological problems
  • Congenital nevi are believed to have an increased risk of malignant transformation over the lifetime of the child. Small and medium sized congenital melanocytic nevi have a risk as low as 1% or less. Large and giant melanocytic nevi have a higher risk of 5-10% over the child’s lifetime
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:
  • Simple topical treatments
  • Minimally invasive procedures
  • Surgical revision with advanced techniques in wound closure

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: 

  • Discoloration or Surface Irregularities: These types of scars do not impair function or cause physical discomfort and include acne scars as well as scars resulting from minor injury and prior surgical incisions.
  • Hypertrophic Scars: Are thick clusters of scar tissue that develop directly at a wound site. They are often raised, red and/or uncomfortable and may become wide over time. They can be hyperpigmented (darker in color) or hypopigmented (lighter in color).
  • Keloid: Keloids are larger than hypertrophic scars. They can be painful or itchy and may also pucker. They extend beyond the edges of an original wound or incision. Keloids can occur anywhere on the body, but they develop more commonly where there is little underlying fatty tissue, such as the face, neck, ears, chest or shoulders.
  • Contractures: Contractures are scars that restrict movement due to skin and underlying tissue that pull together during healing. They can occur when there is a large amount of tissue loss, such as after a burn. Contractures also can form when a wound crosses a joint restricting movement of the fingers, elbows, knees or neck.

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.

 

American College of Obstetricians and Gynecologists (ACOG)

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.

 

Prior Approval:

Not required

 

Policy:

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. 

 

Reconstructive Surgery

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:  

  • Illness or injury; or
  • Birth defect

 

Required Documentation

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:

  • History of medical conditions requiring treatment or surgical intervention which includes all of the following:
    • To prove medical necessity, a well-defined physical/physiologic abnormality resulting in a medical condition that requires treatment
    • Recurrent or persistent functional impairment caused by the abnormality
  • Clinical studies/tests addressing the physical/physiologic abnormality confirming its presence and degree to which it causes impairment
  • Physician plan of care with proposed procedures and whether this request is part of a staged procedure; indicate how the procedure will improve and/or restore function. 

 

Breast Reconstruction Following Mastectomy

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. 

 

Cosmetic Services

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: 

 

Procedure/Service

  • Treatment for any complications resulting from a noncovered cosmetic procedure/service or drug(s)
  • Abdominoplasty (including both mini or modified abdominoplasty) including:  
    • Correction of diastasis recti repair for any indication
    • Repairing abdominal wall laxity
    • When performed in conjunction with abdominal or gynecological procedure (not an all-inclusive list) such as abdominal hernia repair, hysterectomy or obesity surgery
  • Abdominal etching (new liposuction technique that creates a muscular, rippled appearance in the abdominal area) (SmartLipo)
  • Areola reduction except when performed with post-mastectomy breast reconstruction, see above; can be performed with breast lift [mastopexy]; breast reduction; or breast augmentation for aesthetic purposes  
  • Arm lift (brachioplasty)
  • Blepharoplasty – lower eyelid
  • Blepharoplasty – upper lid when performed for aesthetic purposes and in the absence of visual field symptoms
  • Body lift /torsoplasty (abdominal area – locally or extending around the sides into the lower back area; buttocks; thigh – the inner, outer or posterior thigh, or the thighs circumference)
  • Body contouring or excessive/redundant skin removal from limbs and other areas of the body
  • Breast augmentation except post-mastectomy breast reconstruction, see above; or for gender reassignment when prior approval requirements met
  • Breast implant removal except post-mastectomy breast reconstruction, see above
  • Breast implant revision except post-mastectomy breast reconstruction, see above
  • Breast lift (mastopexy) except post-mastectomy breast reconstruction, see above
  • Breast Reduction when performed for aesthetic purposes - solely to improve the patient’s appearance in the absence of symptoms or functional abnormalities/impairments
  • Brow lift/brow ptosis/forehead lift when performed for aesthetic purposes – solely to improve the patient’s appearance in the absence of visual or functional impairment
  • Buccal fat removal (cheek reduction)
  • Buttock enhancement (gluteal augmentation and lift)
  • Calf augmentation (restore leg contour)
  • Canthopexy for aesthetic purposes – solely to improve the patient’s appearance in absence of functional impairment
  • Cervicoplasty (Neck lift or tuck) – lower rhytidectomy
  • Cheek augmentation (cheek enhancement)
  • Chemical exfoliation for active acne and acne scarring
  • Chin surgery (mentoplasty/genioplasty/chinplasty) when performed for aesthetic purposes
  • Dermal fillers/injectable dermal fillers used to sculpt body contours (diminish facial lines and restore volume and fullness)
  • Ear or body piercing
  • Electrolysis/laser hair removal except when related to permanent hair removal for gender reassignment surgery when prior approval requirements are met (note: permanent facial hair removal for gender reassignment surgery is considered cosmetic)
  • Facelift surgery – Rhytidectomy
  • Facial implants for facial balancing and enhancing (may include the following: chin implant to increase the size and projection of the chin that is not proportion with the forehead and midface; jaw implant to increase the width of the lower third of the face; cheek implants to increase the projection of the cheekbones)
  • Fat graft(s) for fat transfer(s) except when performed with post-mastectomy breast reconstruction, see above
  • Hair transplant (surgical hair replacement)
  • Laser skin resurfacing (also known as laser peel, laser vaporization) to reduce wrinkles, scars and blemishes including but not limited to the following:
    • Acne scarring
    • Age spots/brown spots
    • Melasma (brown to grey-brown patches on the face)
    • Rosacea
    • Wrinkles
  • Lipectomy (arms, abdomen, buttocks, thighs and legs), except post-mastectomy breast reconstruction, see above
  • Liposuction/Liposuction Assisted (laser or ultrasound assisted)
  • Mommy Makeover (restore the shape and appearance after childbearing: procedures may include breast augmentation, breast lift (mastopexy), buttock augmentation, liposuction, tummy tuck, vaginal rejuvenation)
  • Nonsurgical fat reduction (using heat, cooling or an injected medication to reduce fat cells)
    • Cryolipolysis (e.g. CoolSculpting)
    • Injection lipolysis (e.g. Kybella, see Pharmaceutical Agents below)
    • Radiofrequency lipolysis (e.g. Vanquish)
    • Laser lipolysis (e.g. SculpSure)
  • Otoplasty (ear surgery)
  • Panniculectomy when performed for aesthetic purposes – to solely improve the patient’s appearance in the absence of symptoms or functional abnormalities/impairments
  • Penis enhancement surgery
  • Removal of frown lines
  • Rhinoplasty when performed for aesthetic purposes - solely to improve the patient’s appearance in the absence of symptoms or functional abnormalities/impairments
  • Skin rejuvenation and resurfacing/targeted phototherapy using laser therapy to include treatment of rosacea and vitiligo, examples of skin rejuvenation and resurfacing treatment methods include, but are not limited to the following:
    • Laser (Excimer laser) and Intense Light (IPL) Treatments (used to remove discoloration and/or tighten sagging skin)
    • Chemical peels (various acid peels/pastes used in different combinations to remove damaged outer skin layers)
    • Ablative laser treatments (fractional, CO2 lasers [remove outer layers of skin to smooth lines and wrinkles])
    • Mechanical ablation (dermabrasion, dermaplaning [surgical scraping methods to soften skin surface irregularities])
    • Non-ablative treatments (microdermabrasion, microneedling, light acid peels [minimally invasive sanding methods to treat light scarring and discolorations])
  • Spider vein treatment (telangiectasia)
  • Tattooing of nipples except with post-mastectomy breast reconstruction, see above
  • Tattoo removal (laser treatments, chemical peels, dermabrasion and surgical excision)  
  • Thigh lift (reshaping of the thighs)
  • Treatment for skin wrinkles
  • Tummy tuck (also known as abdominoplasty)
  • Vaginal rejuvenation nonsurgical and surgical
    • Nonsurgical
      • Radiofrequency (Protégé Intima, Pelleve RF, ThermiVa)
      • Laser energy (MonaLisa Touch, FemiLift-Femilift Probe/FemiLift Slim Probe, FemiTight, CO2 RE Intima; IntimaLase Er YAG laser [Fontona Smooth SP, FotonaSmooth XS Er YAG])
      • Dermal filler injections, see Pharmaceutical agents below
    • Surgical (aesthetic alterations of the female genitalia)
      • Clitoral reduction
      • Hymenoplasty or revirgination procedure
      • G-spot amplification
      • Pubic liposuction or lift
      • Vaginal labiaplasty (reducing the length of the labia minora or changing the shape of the labia minora)
      • Vaginoplasty/Designer Vaginoplasty (tightening up of the vagina that becomes slack or loose from vaginal childbirth or aging)

 

Pharmaceutical Agents

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)

  • Egrifta (tesamorelin)
  • Juvederm
  • Kybella (deoxycholic acid) injection
  • Latisse (bimatoprost)
  • Radiesse
  • Sculptra
  • 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    

 

Policy Guidelines

Determination of Eligibility of Coverage

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). 

 

Administering the Contract Language

The following general principles describe the issues to be determined in properly administering contract language:

  1. The eligibility of a service for coverage may be based on either a specific benefit addressing cosmetic or reconstructive services or on its specific exemption or exclusion for cosmetic or reconstructive services or both.
  2. Cosmetic services are usually considered to be those that are primarily to restore appearance and that otherwise do not meet the definition of reconstructive. The definition of reconstructive may be based on two distinct factors:
    1. Whether the service is primarily indicated to improve or correct a functional impairment or is primary to improve appearance; and
    2. The etiology of the defect (e.g. congenital anomaly, anatomic variant, result of trauma, post-therapeutic intervention, disease process).
  3. The presence or absence of a functional impairment is a critical point in interpreting coverage eligibility.  

 

Benefit Application

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:

  • First, it must be determined whether a functional impairment is present that would render its treatment medically necessary and therefore eligible for coverage if no other exclusions apply.
  • Second, if no functional impairment is present, the etiology of the condition must be determined, and the contract language reviewed to see if this etiology is included in the definition of Reconstructive Services or Cosmetic Services (Not Covered).  

 

Definitions

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:

  • Smallpox vaccination when payment for such treatment is not available through workers compensation or government-sponsored programs; or
  • A noncovered abortion.  

 

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:

  • Reconstruction of the breast on which the mastectomy has been performed.
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance.
  • Prostheses.

 

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.  

 

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.

 

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
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:

  •  Laser skin resurfacing (also known as laser peel, laser vaporization) to reduce wrinkles, scars and blemishes including but not limited to the following:
    • Acne scarring
    • Age spots/brown spots
    • Melasma (brown to grey-brown patches on the face)
    • Rosacea
    • Wrinkles; and
  • Skin rejuvenation and resurfacing/targeted phototherapy using laser therapy
    • Laser (Excimer laser) and Intense Light (IPL) Treatments (used to remove discoloration and/or tighten sagging skin)
    • Chemical peels (various acid peels used in different combinations to remove damaged outer skin layers)
    • Ablative laser treatments (fractional, CO2 lasers [remove outer layers of skin to smooth lines and wrinkles])
    • Mechanical ablation (dermabrasion, dermaplaning [surgical scraping methods to soften skin surface irregularities])
    • Non-ablative treatments (microdermabrasion, microneedling, light acid peels [minimally invasive sanding methods to treat light scarring and discolorations]) 
96999 Unlisted special dermatological services or procedure

Note: See above cosmetic procedure list regarding the following:

  • Laser skin resurfacing (also known as laser peel, laser vaporization) to reduce wrinkles, scars and blemishes including but not limited to the following:
    • Acne scarring
    • Age spots/brown spots
    • Melasma (brown to grey-brown patches on the face)
    • Rosacea
    • Wrinkles; and
  • Skin rejuvenation and resurfacing/targeted phototherapy using laser therapy
    • Laser (Excimer laser) and Intense Light (IPL) Treatments (used to remove discoloration and/or tighten sagging skin)
    • Chemical peels (various acid peels used in different combinations to remove damaged outer skin layers)
    • Ablative laser treatments (fractional, CO2 lasers [remove outer layers of skin to smooth lines and wrinkles])
    • Mechanical ablation (dermabrasion, dermaplaning [surgical scraping methods to soften skin surface irregularities])
    • Non-ablative treatments (microdermabrasion, microneedling, light acid peels [minimally invasive sanding methods to treat light scarring and discolorations])

 

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.

CPT CodeDescription
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

 

Selected References:

Administrative determinations based on contract benefits, refer to the member's benefit document.

  • American Society of Plastic Surgeons (ASPS). Cosmetic, Reconstructive, and Plastic Surgery descriptions. Accessed January 2021.
  • The American College of Obstetricians and Gynecologists (ACOG), Committee Opinion Number 378, September 2007 (Reaffirmed 2019), Vaginal “Rejuvenation” and Cosmetic Vaginal Procedures, Obstet Gynecol 2007;110:737-738

 

Policy History:

  • January 2021 - Annual Review, Policy Revised
  • January 2020 - Annual Review, Policy Renewed
  • November 2019 - Interim Review, Policy Revised
  • September 2019 - Interim Review, Policy Revised
  • February 2019 - Annual Review, Policy Revised
  • May 2018 - Annual Review, Policy Renewed
  • May 2017 - Annual Review, Policy Revised
  • June 2016 - Annual Review, Policy Revised
  • August 2015 - Annual Review, Policy Revised
  • January 2015 - Interim Review, Policy Revised
  • September 2014 - Annual Review, Policy Renewed
  • October 2013 - Annual Review, Policy Renewed
  • November 2012 - Annual Review, Policy Renewed
  • November 2011 - Annual Review, Policy Renewed
  • May 2011 - Interim Review, Policy Renewed
  • October 2010 - 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.

 

*CPT® is a registered trademark of the American Medical Association.