Description:
Reconstructive surgery is generally considered a service that "returns the patient to whole." These procedures or services are performed on structures of the body to improve or restore a body function or to correct a deformity that has resulted from a disease process, trauma, congenital or developmental anomaly or previous therapeutic intervention.

Cosmetic surgery or services are those services that are intended to reshape structures of the body to alter the individual's appearance or to alter the manifestations of the aging process ONLY.

Certain procedures, however, may be considered either cosmetic or reconstructive, based on the condition of the patient and on the purpose and intent of the procedure.  Please see page 2 for examples.

Policy:
Cosmetic surgery is typically a standard exclusion in the plan of benefits administered by this health plan. Please review specific contract verbiage for exclusions, limitations and/or maximums.

There are no reimbursement provisions for cosmetic surgery or services due to psychiatric and/or emotional distress.

Reconstructive surgery is typically a covered benefit under the following criteria:

• The procedure is intended to primarily improve or restore a bodily function or to correct a deformity resulting from disease, trauma or previous therapeutic intervention.
• The procedure is intended to correct a congenital or developmental anomaly that has caused significant functional impairment.

Contract provisions and limitations for reconstructive surgery and services vary from each plan of benefits.

Please review specific contract verbiage for exclusions, limitations and/or maximums.

Examples of Cosmetic and Reconstructive Procedures
The table listed below is NOT all-inclusive; however, it does provide examples of both cosmetic and reconstructive procedures. **For specific benefit guidelines, please refer to the specific plan of benefit.**

**Requests/appeals for services denied as cosmetic will be reviewed for medical necessity on rebuttal by the specific plan of benefit's medical director.**

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 due 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.

References:

1. Hoeyberghs JL. Fortnightly review: Cosmetic surgery. BMJ. 1999;318(7182):512-516.
2. Kuzon WM Jr. Plastic surgery. J Am Coll Surg. 1999;188(2):171-177.
3. Hallock GG. Cosmetic trauma surgery. Plast Reconstr Surg. 1995;95(2):380-381.
4. Amaral MJ. Plastic surgery or esthetic surgery? Acta Med Port. 1998;11(2):97-99.
5. Mogelvang C. Cosmetic versus reconstructive surgery. Plast Reconstr Surg. 1997;99(7):2115-2116.
6. American Society of Plastic Surgeons Practice Parameter for Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients, 07/06.
7. Centers for Medicare & Medicaid Services (CMS) National Coverage Determination (NCD) for Plastic Surgery to Correct Moon Face (140.4), 05/01/89. Accessed 07/29/13.
8. Federal Law SEC. 713 Required coverage for reconstructive surgery following mastectomies, 2008

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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