Cosmetic and Reconstructive Services

• Notice
• Benefit Application
• Description
• Prior Approval
• Policy
• Procedure Codes
• Selected References
• Policy History

 

Medical Policy: 10.01.02 

Original Effective Date: January 1994 

Reviewed: January 2021 

Revised: May 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.  

 

 

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. 

 

 

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: 

 

Cosmetic Procedures/Services

• 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)
• Asymptomatic varicose vein treatment
• 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
  • Vitiligo
  • 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 but not limited to the treatment of rosacea, vitiligo, acne scarring/skin disorders (age spots/brown spots), melasma (brown to gray-brown patches on the face) and wrinkles; 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) using sclerotherapy (Asclera, Sotradecol); laser treatments PhotoDerm, VeinLase, Vasculite or focused thermal energy Veinwave or VeinGogh Thermolysis System
• 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

 

 

The following list (s) of procedure codes may not be all inclusive.

 

Unlisted codes can be reported for many services and may be considered a non-covered benefit, medically necessary, not medically necesseary or investigational depending on the service. The following unlisted 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. 

 

 

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.

 

The following list(s) of procedure codes may not be all inclusive. Unlisted codes can be reported for many services and may be considered a non-covered benefit, medically necessary, not medically necessary or investigational depending on the service. The following unlisted codes lack a specific CPT or HCPCS code and 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.

 

 

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:

• May 2021 - Interim Review, Policy Revised
• February 2021 - Interim Review, Policy Revised
• 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.