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Date Printed: June 23, 2017: 11:44 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-12000-01

Original Effective Date: 02/15/02

Reviewed: 03/23/17

Revised: 04/15/17

Subject: Reconstructive Surgery/Cosmetic Surgery

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates  
           

DESCRIPTION:

Reconstructive surgery and related services are procedures that are performed on structures of the body to improve or restore bodily function or to correct a deformity resulting from disease, trauma, congenital or developmental anomalies, or previous medical treatments. Reconstructive services also include those procedures, which treat significant medical symptoms such as pain, bleeding, or chronic infections.

Cosmetic surgery and related services are procedures that are performed to reshape structures of the body in order to alter or improve an individual’s appearance, self-perception, or alter the manifestations of the aging process. Cosmetic surgical procedures do not restore bodily functions or correct deformities resulting from trauma, congenital or developmental anomalies or previous medical treatments.

Cosmetic surgery does not become reconstructive surgery because of psychological or psychiatric reasons.

POSITION STATEMENT:

 

Certificate of Medical Necessity - Septoplasty

Submit a completed Certificate of Medical Necessity (CMN) along with your request for septoplasty to expedite the medical review process.

1. Click the link Septoplasty - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

NOTE: Coverage for reconstructive surgery and cosmetic surgery is subject to the member’s benefit terms, limitations and maximums. Some plans may exclude coverage for reconstructive surgery and cosmetic surgery. Refer to specific contract language regarding reconstructive surgery and cosmetic surgery.

Reconstructive surgery and related services performed on structures of the body to improve or restore bodily function or to correct a deformity resulting from disease, trauma, and congenital or developmental anomalies meets the definition of medical necessity.

Surgery for reconstructive procedures requires medical review. The following information is required documentation for medical review: physician history and physical, physician operative report, pathology report, and attending physician visit notes that include documentation of medical indication. Photos are not required with the initial review. Photos should be maintained as part of the medical record. BCBSF may request photos as part of the review process.

Surgery and related services is considered cosmetic in nature and is generally a contract exclusion for the following indications:

Examples of Reconstructive Procedures (Not all inclusive):

Bilateral reconstruction of the affected breast and the unaffected breast may be covered when performed following a medically necessary mastectomy. Refer to Prophylactic Mastectomy 02-12000-15 and “OTHER” section of this guideline, coverage for surgical procedures and devices incident to mastectomy.

Blepharoplasty eye lid and brow surgical procedures. Refer to Blepharoplasty/Brow Surgical Procedures 02-65000-11

Brachioplasty (arm lift) meets the definition of medical necessity when done in the presence of a functional impairment cause directly by the excess skin (e.g., redundant or excessive skin is interfering with activities of daily living or causing persistent dermatitis, cellulitis, skin ulcerations, physical deformity or disfigurement) and the functional impairment is refractory to 3 months of continuous medical therapy (e.g., topical or systemic treatments for infection) and the procedure is expected to restore or improve the functional impairment.

Brachioplasty (arm lift) do not meet the definition of medical necessity when done for aesthetic improvement to excessive or laxity skin of the upper arm).

Breast asymmetry surgical reconstruction of breast deformity (e.g., Poland’s syndrome)

Refer to “OTHER” section of this guideline, coverage for surgical procedures and devices incident to mastectomy.

Breast augmentation refer to Reduction Mammoplasty 02-12000-11

Post surgical reconstruction of deformity (e.g., Poland’s syndrome-insertion of subcutaneous tissue expanders)

Refer to “OTHER” section of this guideline, coverage for surgical procedures and devices incident to mastectomy.

Breast implant: insertion and removal: post mastectomy reconstruction. Removal due to complications from an implant (e.g., rupture, leakage, infection). Refer to Prophylactic Mastectomy 02-12000-15 (e.g., Poland’s syndrome-insertion of subcutaneous tissue expanders).

Refer to “OTHER” section of this guideline, coverage for surgical procedures and devices incident to mastectomy.

Breast implant repositioning: post surgical mastectomy reconstruction. Refer to Prophylactic Mastectomy 02-12000-15
(e.g., Poland’s syndrome-insertion of subcutaneous tissue expanders).

Chin implant for deformities of the maxilla or mandible resulting from trauma or disease.

Congenital anomalies a physical developmental defect that is present at birth, which do not result in functional impairment but which are so severely disfiguring as to merit consideration for corrective surgery are reviewed for individual consideration (e.g., cranio-facial anomalies associated with Crouzon’s syndrome and Treacher-Collins syndrome, etc.).

Congenital deformities in children are reviewed for individual consideration and may include (e.g., cleft lip and palate, deforming hemangiomas, pectus excavatum, syndactyly, macrodactylia (macrodactyly).

Dermabrasion. Refer to Dermabrasion; Chemical Peel; Salabrasion 02-12000-08

Dermal and epidermal chemical peels. Refer to Dermabrasion; Chemical Peel; Salabrasion 02-12000-08

Disfigurement of the face resulting from deformity, trauma, or disease. Procedures performed to correct disfigurement of the face.

Ear lobe repair (e.g., tear) of an acute traumatic injury meets the definition of medical necessity.

Ear lobe repair to close a stretched pierce hole is considered cosmetic and does not meet the definition of medical necessity.

Lifts (buttock, thigh) meets the definition of medical necessity when there is a functional impairment caused directly by the excess skin (e.g., redundant or excessive skin is interfering with activities of daily living or causing persistent dermatitis, cellulitis, skin ulcerations, physical deformity or disfigurement) and the functional impairment persists is refractory to 3 months of continuous medical therapy (e.g., topical or systemic treatments for infection) and the procedure is expected to restore or improve the functional impairment.

Lifts (buttock, thigh) do not meet the definition of medical necessity when done for aesthetic improvement to excessive or laxity skin of the buttocks and thigh.

Mastectomy for Gynecomastia: Refer to Mastectomy for Gynecomastia 02-12000-14

Mastopexy to correct a pendulous breast following a mastectomy or reconstruction for breast cancer to achieve symmetry (e.g., Poland’s syndrome).

Otoplasty/Pinnaplasty for absence of the ear (anotia) or deformed ears resulting from trauma or disease (e.g., microtia). Otoplasty/pinnaplasty meets the definition of medical necessity when performed to improve hearing in the ear canal.

Otoplasty/pinnaplasty to correct large or protruding ears when the surgery will not improve hearing is considered cosmetic and does not meet the definition of medical necessity.

Panniculectomy Refer to Panniculectomy and Abdominoplasty 02-12000-16

Perineoplasty (perineorrhaphy) to treat vulvodynia (chronic pain and discomfort of the vulva) and vulvar vestibulitis (burning pain during sexual intercourse).

Photoderm/Fotofacial (skin correction, facial rejuvenation)-Intense Pulsed Light laser surgery for treatment of severe cases of rosacea (e.g., redness, inflammation, skin eruptions).

Post mastectomy for breast reconstruction.

Prophylactic Mastectomy Refer to Prophylactic Mastectomy 02-12000-15

Repositioning of breast post mastectomy reconstruction of the remaining breast, including reconstruction of the nipple and areolar complex. Reconstruction of the contralateral (non-diseased) breast may be necessary to achieve symmetry between the two breasts.

Rhinoplasty for external nasal deformity due to trauma or disease, air obstruction from deformities due to disease, congenital abnormality.

Rhytidectomy for correction of functional impairment from facial nerve palsy.

Scar surgery (e.g., dermabrasion) or intralesional steroid injection when the scar(s) interferes with normal bodily function or causes pain. Refer to Dermabrasion; Chemical Peel; Salabrasion 02-12000-08

Scar revisions resulting from trauma or surgery and meets the definition of reconstructive surgery, are covered.

Skin lesions (e.g., skin tags). Refer to Removal of Skin Lesions 02-10000-01

Strabismus treatment in individuals 18 years of age or older are reviewed by individual consideration

Subcutaneous injection of filling material (e.g., collagen) (11950, 11951, 11952, 11954) is typically a purified material derived from bovine hide dispersed in a saline solution and injected with a local anesthetic into the tissues. Collagen injections may be covered when performed to repair facial congenital anomalies and/or facial trauma that result in functional impairment.

Reimbursement for collagen injections is based on medical review of photographs and documentation describing the medical indications for the procedure.

Tattoos

Tattooing of the areola as part of a nipple reconstruction following a covered mastectomy.
Tattooing for radiation therapy planning.

Vascular birth marks salmon patch [nevus simples], strawberry hemangioma, port-wine stain [nevus flammeus] on the face, neck, or other body areas when functional impairment is documented.

Examples of Cosmetic Procedures (Not all inclusive):

Abdominoplasty. Refer to Panniculectomy and Abdominoplasty 02-12000-16

Breast augmentation of small but otherwise normal and symmetrical breasts or to create symmetry between normal breasts.

Breast implant repositioning to reposition a displaced implant when the original procedure was performed for cosmetic enhancements.

Breast reconstruction (implant insertion and removal) for cosmetic enhancements.

Chin implant not the result of disease or trauma or deformity.

Dermabrasion Refer to Dermabrasion; Chemical Peel; Salabrasion 02-12000-08

Dermal and epidermal chemical peels Refer to Dermabrasion; Chemical Peel; Salabrasion 02-12000-08

Dermal fillers (soft tissue fillers) or filler injections (e.g., injectable dermal fillers, injectable implants) to smooth wrinkles or scars or make a body part fuller (e.g., face, nasolabial folds, cheeks, lips, hand).

Diastasis recti Refer to Panniculectomy and Abdominoplasty 02-12000-16

Disfigurement of the face for cosmetic enhancements.

Ear or body piercing

Genitalia to improve and /or enhance the appearance or sexual performance of:

Female genitalia (e.g., vaginal rejuvenation, vaginoplasty, vulvar reconstruction)

Male genitalia (e.g., penile reconstruction)

Hair loss to correct hair loss (e.g., Minoxidil, Rogaine, hair implants, hair transplants).

Hair transplants for male and female pattern baldness or to correct hair loss (e.g., alopecia).

Injection of sclerosing solutions for spider veins (telangiectasia) Refer to Treatments for Varicose Veins 02-33000-31

Inverted nipple to correct nipple inversion for breast enhancement.

Laser resurfacing for wrinkling or aging skin.

Lifts: Buttock or thigh for cosmetic enhancements.

Lipectomy (Suction Assisted Lipectomy (SAL) or liposuction removal of excessive fat to reshape a specific part of the body (e.g., face, neck, arms, abdomen, hips, thighs, breast) for cosmetic reasons.

Mastopexy correction of sagging breast in the absence of a mastectomy for cosmetic enhancements

Breast asymmetry for normal breasts.

Moon face to correct moon face.

Otoplasty for large or protruding ears for cosmetic enhancements.

Panniculectomy/Abdominoplasty Refer to Panniculectomy and Abdominoplasty 02-12000-16

Photoderm/Fotofacial (skin correction, facial rejuvenation)-Intense Pulsed Light for facial spider veins, unsightly leg veins, birthmarks, age spots, sun spots, freckles, tattoos, unwanted hair, varicose veins, rosacea telangiectasia, and vascular lesions or skin conditions (broken capillaries), and hyperpigmentation.

Prophylactic Mastectomy no high risk or moderately increased risk of breast cancer or lobular carcinoma in situ (LCIS).

Refer to Prophylactic Mastectomy 02-12000-15 and Mastectomy for Gynecomastia 02-12000-14

Removal of breast tissue in the male for gynecomastia. Refer to Mastectomy for Gynecomastia 02-12000-14

Removal of excessive hair including excessive hair caused by a physical or medical disorder (e.g., electrolysis for hirsutism).

Removal of excess skin to improve appearance after surgical procedure (e.g., liposuction or lipectomy, bariatric surgery) or weight loss when there is no functional impairment from the excess skin.

Removal of scar(s) for removal of acne scar(s) for cosmetic enhancements.

Repositioning of breast for cosmetic enhancements.

Rhinoplasty for external nasal deformity not due to trauma or disease; for cosmetic enhancements.

Rhytidectomy of the face for aging skin, face lifts to remove wrinkles or frown lines.

Salabrasion Refer to Dermabrasion; Chemical Peel; Salabrasion 02-12000-08

Skin wrinkling cosmetic surgery and procedures or supplies to correct skin wrinkling.

Tattoos Removal of and treatment of decorative tattoos (e.g., eyebrow, eyelid, body (arms, legs, torso, neck, upper/lower body)).

Vascular birth marks salmon patch [nevus simples], strawberry hemangioma, port-wine stain [nevus flammeus] no functional impairment is documented.

Non-Covered Procedures:

The following procedure codes are considered cosmetic services and are non-covered:

15828

Rhytidectomy; cheek, chin, and neck

15829

Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap

17380

Electrolysis epilation, each ½ hour

69090

Ear piercing

69300

Otoplasty, protruding ear, with or without size reduction

Q2026

Injection Radiesse, 0.1 ml

BILLING/CODING INFORMATION:

Reconstructive Surgery

The following information is required documentation for medical review: physician history and physical, physician operative report, pathology report, and attending physician visit notes that include documentation of medical indication.

LOINC Codes

DOCUMENTATION TABLE

LOINC CODES

LOINC TIME FRAME MODIFIER CODE

LOINC TIME FRAME MODIFIER CODES NARRATIVE

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician operative report

28573-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Pathology report

27898-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

NOTE: Photos are not required with the initial review. Photos should be maintained as part of the medical record. BCBSF may request photos as part of the review process.

The following procedure codes may be used to report reconstructive surgery. The following procedures require medical review.

CPT Coding

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, or part thereof (List separately in addition to code for primary procedure)

11922

Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm

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

11960

Insertion of tissue expander(s) for other than breast, including subsequent expansion

11970

Replacement of tissue expander with permanent prosthesis

15775

Punch graft for hair transplant; 1 to 15 punch grafts

15776

Punch graft for hair transplant; more than 15 punch grafts

15824

Rhytidectomy; forehead

15825

Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)

15826

Rhytidectomy; glabellar frown lines

15830

Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy

15832

Excision, excessive skin and subcutaneous tissue (including lipectomy); thigh

15833

Excision, excessive skin and subcutaneous tissue (including lipectomy); leg

15834

Excision, excessive skin and subcutaneous tissue (including lipectomy); hip

15835

Excision, excessive skin and subcutaneous tissue (including lipectomy); buttock

15836

Excision, excessive skin and subcutaneous tissue (including lipectomy); arm

15837

Excision, excessive skin and subcutaneous tissue (including lipectomy); forearm or hand

15838

Excision, excessive skin and subcutaneous tissue (including lipectomy); submental fat pad

15839

Excision, excessive skin and subcutaneous tissue (including lipectomy); other area

15840

Graft for facial nerve paralysis; free fascia graft (including obtaining fascia)

15841

Graft for facial nerve paralysis; free muscle graft (including obtaining graft)

15842

Graft for facial nerve paralysis; free muscle flap by microsurgical technique

15845

Graft for facial nerve paralysis; regional muscle transfer

15847

Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial placation) (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

17106

Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); less than 10 sq cm

17107

Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); 10.0 to 50.0 sq cm

17108

Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); over 50.0 sq cm

19316

Mastopexy

19324

Mammaplasty, augmentation; without prosthetic implant

19325

Mammaplasty, augmentation; with prosthetic implant

19328

Removal of intact mammary implant

19330

Removal of mammary implant material

19340

Immediate insertion of breast prosthesis following mastopexy, mastectomy, or in reconstruction

19342

Delayed insertion of breast prosthesis following mastopexy, mastectomy, or in reconstruction

19350

Nipple/areola reconstruction

19355

Correction of inverted nipples

19357

Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion

19361

Breast reconstruction with latissimus dorsi flap, without prosthetic implant

19364

Breast reconstruction with free flap

19366

Breast reconstruction with other technique

19367

Breast reconstruction with transverse rectus abdominis flap (TRAM), single pedicle, including closure of donor site

19368

Breast reconstruction with transverse rectus abdominis flap (TRAM), single pedicle, including closure of donor site; with microvascular anastomosis (supercharging)

19369

Breast reconstruction with transverse rectus abdominis flap (TRAM), double pedicle, including closure of donor site

19370

Open periprosthetic capsulotomy, breast

19371

Periprosthetic capsulectomy, breast

19380

Revision of reconstructed breast

19396

Preparation of moulage for custom breast implant

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)

21175

Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (e.g., plagiocephaly, trigonocephaly, brachycephaly), 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)

21244

Reconstruction of mandible, extraoral, with transosteal bone plate (e.g., mandibular staple bone plate)

21245

Reconstruction of mandible or maxilla, subperiosteal implant; partial

21246

Reconstruction of mandible or maxilla, subperiosteal implant; complete

21247

Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) e.g., for hemifacial microsomia)

21248

Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder); partial

21249

Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder); complete

21255

Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)

21256

Reconstruction or 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

Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement

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

30120

Excision or surgical planning of skin or nose for rhinophyma

30400

Rhinoplasty, primary; lateral or 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; major revision (nasal tip work and osteotomies)

30460

Rhinoplasty for nasal deformity secondary to congenital cleft lip AND/OR palate, including columellar lengthen; tip only

30462

Rhinoplasty for nasal deformity secondary to congenital cleft lip AND/OR palate, including columellar lengthen; tip, septum, osteotomies

30465

Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction)

30520

Septoplasty or submucous resection, with or without cartilage scoring contouring or replacement with graft

30620

Septal or other intranasal dermatoplasty (does not include obtaining graft)

40840

Vestibuloplasty; anterior

40842

Vestibuloplasty; posterior, unilateral

40843

Vestibuloplasty; posterior bilateral

40844

Vestibuloplasty; entire arch

40845

Vestibuloplasty; complex (including ridge extension, muscle repositioning)

54660

Insertion of testicular prosthesis (separate procedure)

56810

Perineoplasty, repair of perineum nonobstetrical (separate procedure)

67909

Reduction of overcorrection of ptosis

67911

Correction of lid retraction

67914

Repair of ectropion; suture

67915

Repair of ectropion; thermo-cauterization

67916

Repair of ectropion; excision tarsal wedge

67917

Repair of ectropion; extensive (e.g., tarsal strip operation)

67921

Repair of entropion; suture

67922

Repair of entropion; thermo-cauterization

67923

Repair of entropion; excision tarsal wedge

67971

Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; up to two-thirds of eyelid, l stage or first stage

67973

Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, lower, 1 stage or first stage

67974

Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, upper, 1 stage or first stage

67975

Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; second stage

HCPCS CODING

L8600

Implantable breast prosthesis, silicone or equal

S2066

Breast reconstruction with gluteal artery perforator (GAP) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral

S2067

Breast reconstruction of a single breast with “stacked” deep inferior epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator (GAP) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast

S2068

Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral

Cosmetic Surgery

The following information is required documentation for medical review: physician history and physical, physician operative report, pathology report, and attending physician visit notes that include documentation of medical indication.

LOINC Codes

DOCUMENTATION TABLE

LOINC CODES

LOINC TIME FRAME MODIFIER CODE

LOINC TIME FRAME MODIFIER CODES NARRATIVE

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician operative report

28573-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Pathology report

27898-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

The following procedure codes may be used to report cosmetic surgery and may be considered cosmetic services.

The following procedures require medical review.

CPT Coding

15819

Cervicoplasty

15832

Excision, excessive skin and subcutaneous tissue (including lipectomy); thigh

15833

Excision, excessive skin and subcutaneous tissue (including lipectomy); leg

15834

Excision, excessive skin and subcutaneous tissue (including lipectomy); hip

15835

Excision, excessive skin and subcutaneous tissue (including lipectomy); buttock

15836

Excision, excessive skin and subcutaneous tissue (including lipectomy); arm

15837

Excision, excessive skin and subcutaneous tissue (including lipectomy); forearm or hand

15838

Excision, excessive skin and subcutaneous tissue (including lipectomy); submental fat pad

15839

Excision, excessive skin and subcutaneous tissue (including lipectomy); other area

21137

Reduction forehead; contouring only

56805

Clitoroplasty for intersex state

57335

Vaginoplasty for intersex state

67715

Canthotomy (separate procedure)

67950

Canthoplasty (reconstruction of canthus)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products:

No Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Plastic Surgery to Correct Moon Face (140.4) located at cms.gov.

DEFINITIONS:

Blepharochalasis: drooping, sagging eyelids.

Blepharoplasty: surgical removal of excess skin of the eyelids.

Capsulotomy: incision of a capsule (i.e., eye or joint).

Congenital disorder: known to result in significant impairment of health or intellect.

Crouzon’s syndrome: an inherited disorder that is controlled by an autosomal dominant gene, and is characterized by malformation of the skull duet to premature ossification and closure of sutures and by widely spaced eyes, abnormal protrusion of the eyeballs, a beaked nose, underdeveloped of the maxilla with protrusion of the mandible.

Dermabrasion: planing of the skin, done by mechanical means (i.e., rotary power sander, sandpaper, wire brushes).

Genioplasty: surgical correction of the chin and lip.

Hemangioma: a usually benign tumor made up of blood vessels that typically occurs as a purplish or reddish slightly elevated area of skin.

Hirsutism: excessive growth of hair of normal or abnormal distribution.

Macrodactylia (macrodactyly): abnormal largeness of the fingers and toes.

Mammaplasty: surgical reconstruction of the breast to augment or reduce its size.

Mastopexy: surgical repair of pendulous breasts.

Mentoplasty: surgical correction of chin deformities.

Micrognathism: receding chin and jaw.

Microtia: absence of the external part of the ear.

Moon face: the full rounded facies characteristic of hyperadrenocorticism.

Osteotomy, osteoplasty: plastic surgery of bones.

Otoplasty: surgical correction of ear deformities.

Pectus excavatum (funnel chest): a depression of the anterior wall of the chest produced by a sinking in of the sternum.

Poland’s syndrome: a developmental disorder that is present at birth (congenital) and occurs in males and females. The classic features include the following: absence of sternal head of the pectoralis major, hypoplasia AND/OR aplasia of breast or nipple, deficiency of subcutaneous fat and axillary hair, abnormalities of rib cage, upper extremity anomalies (short -upper arm, forearm, or fingers [brachysumphalangism]), hypoplasia or aplasia or serratus, external oblique, pectoralis minor, latissimus dorsi, infraspinatus, and supraspinatus muscles, total absence of anterolateral ribs and herniation of lung, and symphalangism with anydactyly and hypoplasia or aplasia of the middle phalanges. Physical abnormalities may be confined to one side of the body (unilateral).

Rhinophyma: disease in which the nose is large, red, swollen with abnormal skin (rosacea).

Rhinoplasty, septorhinoplasty, septoplasty: surgical repair of the nose AND/OR septum.

Rhytidectomy: surgical removal of wrinkles (face-lift).

Syndactyly: a hereditary disorder marked by the joining or webbing or two or more fingers or toes.

Treacher Collins Syndrome (mandibulofacial dysostosis, Franceschetti-Klein Syndrome): a rare genetic syndrome that involves facial disfigurement and hearing loss.

Vascular birthmarks (salmon patch [nevus simples], strawberry hemangioma, port-wine stain [nevus flammeus]: a discoloration of the skin that is caused by malformations of blood vessels. They are present at birth or appear shortly after birth.

RELATED GUIDELINES:

Blepharoplasty/Brow Surgical Procedures, 02-65000-11
Dermabrasion; Chemical Peel; Salabrasion, 02-10000-08

Mastectomy for Gynecomastia, 02-12000-14

Orthognathic Surgery, 02-12000-15

Panniculectomy and Abdominoplasty, 02-12000-16

Prophylactic Mastectomy, 02-12000-15

Prosthetics, 09-L0000-05

Reduction Mammoplasty, 02-12000-11

Surgery for Clinically Severe Obesity (Bariatric Surgery; Gastric Bypass Surgery), 02-40000-10

Treatments for Varicose Veins/Venous Insufficiency, 02-33000-31

OTHER:

Federal Law-SEC 713 Required Coverage for Reconstructive Surgery following Mastectomies

A group health plan, and a health insurance issuer providing health insurance coverage in connection with a group health plan, that provides medical and surgical benefits with respect to a mastectomy shall provide, in a case of a participant or beneficiary who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy, coverage for:

(1) All stages of reconstruction of the breast on which the mastectomy has been performed;

(2) Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

(3) Prostheses and physical complications all stages of mastectomy, including lymphedemas; in a manner determined in consultation with the attending physician and the patient.

Florida Statute-Chapter 627 – 627.6417 Coverage for surgical procedures and devices incident to mastectomy.

Any health insurance policy that provides coverage for mastectomies must also provide coverage for prosthetic devices and breast reconstructive surgery incident to the mastectomy. Breast reconstructive surgery must be in a manner chosen by the treating physician, consistent with prevailing medical standards, and in consultation with the patient. The term "mastectomy" means the removal of all or part of the breast for medically necessary reasons as determined by a licensed physician and the term "breast reconstructive surgery" means surgery to reestablish symmetry between the two breasts.

REFERENCES:

  1. American Society of Plastic Surgeons (ASP). Dermal Fillers, 2017.
  2. American Society of Plastic Surgeons Practice Parameter for Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients, 07/06.
  3. Blue Cross Blue Shield Association Medical Policy Reconstructive/Cosmetic Services 10.01.09, 10/09/03; Archived December 2011.
  4. Federal Law SEC. 713 Required coverage for reconstructive surgery following mastectomies, 2008.
  5. Florida Statute-Chapter 383 (383.14) Maternity and Infancy Hygiene-383.14 Screening for metabolic disorders, other hereditary and congenital disorders, and environmental risk factors, 2008.
  6. Florida Statute-Chapter 627 (627.6417) Coverage for surgical procedures and devices incident to mastectomy, 2008.
  7. FDA Medical Devices: Soft Tissue Fillers (Dermal Fillers), 06/26/15.
  8. Food and Drug Administration Soft Tissues Approved by the Center for Devices and Radiological Health, 02/06/17.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/23/17.

GUIDELINE UPDATE INFORMATION:

12/31/00

Medical Coverage Guideline developed.

02/15/02

Reformatted Procedure and diagnosis coding updated.

08/15/02

Revision to cosmetic procedure codes.

08/19/03

Deleted 15824, 15829, and 17380 from the reconstructive surgery section under the Billing/Coding section of the guideline. Code 15821, 15829, and 17380 is as “always considered cosmetic services.”

03/15/04

Annual review. Revised description section to clarify reconstructive services. Revised when services are not covered section; added to correct wrinkles, female, and correct hair loss.

10/15/04

Annual review. Revised and reformatted guideline.

01/01/06

Annual HCPCS coding update: revised descriptor for 67901 and 67902. Added S2068.

06/15/06

Deleted the requirement of photographs for documentation.

07/15/06

Added note regarding maintaining photos as part of the medical record.

08/15/06

Revised CPT coding; delete 15810, 15811 and 21280 (deleted codes), add 21260 (possible reconstructive), 56805 and 57335 (possible cosmetic) revise descriptors for: 11951, 11952, 11954, 19367, 19368, 19369, 21141, 21182, 21183, 21184, 21230, 43846, 43848, and 67909 and list specific code in code range for: 15831 – 15839, 17106 – 17108, 21240 – 21243, 21244 – 21256, 21261 – 21263, 21267 – 21268, 40840 – 40845, 43850 – 43855 and 43860 – 43865. Added, “breast” to lipectomy/liposuction under WHEN SERVICES ARE NOT COVERED, examples of cosmetic procedures. Updated references and related Internet links.

11/15/06

Deleted 17340, 17360, 21083 and 21087. Added 67715 and 67950 to the BILLING/CODING INFORMATION section as procedure codes that may be used to report cosmetic surgery.

01/01/07

Annual HCPCS coding update: deleted code 15831 and 19140. Added 15830, 15847, and 19300. Revised 19361 code descriptor.

07/01/07

HCPCS update. Added codes S2066 and S2067. Revised code S2068 code descriptor. Moved code S2068 to billing/coding information reconstructive surgery section. Deleted ICD-9 diagnoses codes that support medical necessity section (none applicable).

08/15/07

Reviewed; coverage statements maintained, guideline reformatted, references updated.

01/01/08

Annual HCPCS coding update: Added L8600. Revised code S2068 descriptor. Updated guideline, added Florida Statute 627.6417.

01/01/09

Annual HCPCS coding update: revised code descriptor for code 11922.

04/15/09

Deleted codes 56805 and 57335 from Medicare Advantage program exception statement. Updated references.

09/15/09

Annual review. Maintain position statements. Deleted 15780 – 15793. Updated references and related Internet links. Added "surgery" to title.

03/15/10

Added codes 67971, 67973, 67974, and 67975.

07/01/10

3rd quarter HCPCS coding update: added Q2026, Q2027, and S0196. Added Medicare Advantage products program exception for dermal injections for the treatment of facial lipodystrophy syndrome (FLS). Updated references.

09/15/10

Code update; added codes 67914, 67915, 67916, 69717, 67921, 67922, and 67923.

10/01/10

4th quarter HCPCS update; deleted codes S0196.

02/15/11

Added code 10040.

03/15/11

Added 15840, 15841, 15842 and 15845.

07/01/11

Revision; formatting changes.

10/15/11

Annual review. Maintain position statements. Updated references.

12/15/11

Revision; CPT code 10040 removed and added to the Acne Treatments guideline.

05/15/12

Code update; deleted 43842, 43843, 43846, 43847, 43848, 43850, 43855, 43860, 43865 and 43999.

07/15/12

Removed CPT codes 36468 and 36469; added both codes to the Treatments for Varicose Veins/Venous Insufficiency guideline.

02/15/13

Added Federal law for reconstructive surgery following mastectomies. Updated references.

07/01/13

Added cross-reference for Panniculectomy and Abdominoplasty, 02-12000-16.

08/15/13

Revision; deleted codes: 19300; refer to Mastectomy for Gynecomastia, 19318; refer to Reduction mammoplasty, 21120, 21121, 21122, 21123, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21181, 21182, 21183, 21184, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210 and 21215 added to Orthognathic Surgery, 21240, 21242 and 21243; refer to Temporomandibular Joint (TMJ) Dysfunction; Diagnosis Treatment, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906 and 67908; refer to Blepharoplasty/Brow Surgical Procedures. Updated program exceptions section and references.

11/15/13

Revision; Added statement for: brachioplasty (arm lift), ear lobe repair, lifts (buttock, thigh), otoplasty, perineoplasty, scar surgery, septoplasty, skin lesions, abdominoplasty, diastasis recti, and genitalia. Revised statement for: congenital anomalies, scar revisions, breast augmentation, dermal and epidermal, removal of excess skin, and rhytidectomy. Deleted code 17999 and 19499 and updated references.

01/01/14

Annual HCPCS coding update; deleted Q2027.

04/15/14

Deleted 15820 and 15821.

02/15/15

Updated reconstructive procedures section; added documentation for septoplasty. Revised billing/coding information.

04/15/17

Added dermal fillers (soft tissue fillers) or filler injections (e.g., injectable dermal fillers, injectable implants) to smooth wrinkles or scars or make a body part fuller (e.g., face, nasolabial folds, cheeks, lips, hand). Added code 21280.

Date Printed: June 23, 2017: 11:44 AM