Local Coverage Article Response to Comments

Response to Comments: Cosmetic and Reconstructive Surgery (DL39051)


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Response to Comments: Cosmetic and Reconstructive Surgery (DL39051)
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Response to Comments
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This article summarizes the comments WPS received for Draft Local Coverage Determinations (LCD) Cosmetic and Reconstructive Surgery DL39051. Thank you for the comments.

Response To Comments


We received the following comments from a CAC member:

B2) removal / revision breast implant. It is unclear from the wording in this section if it applies to any breast implant or only those for reconstruction. Later in the document (analysis) paragraph 2 does state that it DOES cover for removal if placed for cosmetic reasons. Consider clarifying this in the B2 section.

B4) gynecomastia - states coverage for grade III (moderate, extends past areolar margins) and IV or with ptosis/ redundant tissue. There is no Schnur criteria in this LCD. Gynecomastia is 90+% fatty and as should be tied to the patient weight (as female reductions are). Only states need to have for 3-4 months (in summary of evidence section) and "RULE OUT OTHER CAUSES" is not prominent. Consider adding Schnur criteria, remove grade III as a covered criteria to be medically necessary and in summary of evidence separate female reduction from male gynecomastia. They are different indications, procedures, etc.

B8) allows coverage for rhinoplasty following cosmetic rhinoplasty with resultant airway obstruction? this section is muddled

B9) chemical peel for AK. in the attached section on AK, it notes that chemical peel is 'less commonly performed' with cryoablation, laser, ED&C much more common. check frequency, but question if this is within the standard of care in 2021

B12) remove abdominoplasty. this section is on panniculectomy and while that may have medical indications, tightening of the abdominal musculature and translocation of the umbilicus (what converts a panniculectomy to an abdominoplasty does not). Clarify if after bariatric surgery they must also have other s/s (in limitations it says they do - but it is not clear here). "inability to walk normally" - very vague. These patients are/ have been obese and hips, knees, obesity are much more likely to affect ambulation than a panes). Consider removing this indication or adding that other causes of difficult ambulation should be ruled out.

6) make consistent with B2

8) consider adding grade III to not covered. consider adding Schnur criteria to requirements for coverage (or remove from reduction)

Separate reduction from 'mastectomy from gynecomastia'. They are different patient populations, different operations and different coverage criteria. Consider changing wording from "mastectomy for gynecomastia" to "surgical correction of gynecomastia". vast majority of these are excision or liposuction. Liposuction does not address the glandular component and should be coded as liposuction rather than gynecomastia excision and not covered. Stress other causes ruled out

dermabrasion: this is a lesser treatment for rhinophyma. consider adding laser and/ or derma planing as the primary treatments.

panniculectomy: Only panniculectomy for medical indications - an abdominoplasty tightens the muscles and translocates the umbilicus (neither of which help the medical indications listed). Paragraph 8 - says abdominoplasty, but only references panniculecomy - remove abdominoplasty.

WPS thanks you for your comments.
Section B2 has been reworded to clarify removal of breast implant placed for reconstructive or cosmetic purposes

Regarding Section B4, WPS follows the American Society of Plastic Surgeons (ASPS) Recommended Insurance Coverage Criteria for Third-Party Payers. Based on these guidelines Grade III gynecomastia will be covered if it persists for more than 3 to 4 months of unsuccessful medical treatment for pathological gynecomastia. The ASPS states true gynecomastia is due to glandular breast tissue where as in pseudogynecomastia is secondary to fat accumulation. Examples have been added to clarify “other causes”.

In the “summary of evidence” section, Gynecomastia has been separated from Breast Reduction. According to the CPT code book, CPT code 19300 is Mastectomy for Gynecomastia. This is the only covered CPT code for gynecomastia so referencing surgery for this condition will remain Mastectomy for Gynecomastia.

Section B8 states a congenital nasal airway obstruction that has not resolved after previous septoplasty/turbinectomy. There is an exclusion to rhinoplasty if done for cosmetic reasons. If a patient has previous cosmetic rhinoplasty and suffers vestibular stenosis in the future, they would qualify for rhinoplasty under Medicare reimbursement.

WPS has an LCD L35498 that covers Removal of Benign Skin Lesions. This LCD covers laser, cryosurgery and curettement for actinic keratosis. Coverage of chemical peel for actinic keratosis is not exclusive and is based on NCD 250.4 Treatment for Actinic Keratosis. Since it can be performed for both cosmetic and reconstructive reasons it will remain in the policy as stated.

Section B12 states abdominal lipectomy/panniculectomy and does not state abdominoplasty in the verbiage. Billing and Coding article DA58774 did state under “Documentation Requirement for Specific Services” “Abdominoplasty” and that has been corrected to “Abdominal Lipectomy/Panniculectomy”. Clarification was added to state “inability to walk normally due to pannus size”.

Literature supports dermabrasion as a treatment that promotes complete healing in patients with rhinophyma. There was no literature submitted to support laser or dermaplaning is effective when used as a primary treatment for rhinophyma. If literature is provided in the future to support this, it will be considered.

Paragraph 8 in the summary of evidence does not discuss abdominoplasty other than to state there are many studies focused on clinical outcomes of abdominoplasty in comparison to abdominal lipectomy. Paragraph 8 is supporting abdominal lipectomy as a safe and effective procedure and will remain as written.


A physician from St Louis University School of Medicine commented that they found the proposed policy on cosmetic and reconstructive surgery to be fair.

WPS thanks you for your comment.

Associated Documents

Related Local Coverage Documents
L39051 - Cosmetic and Reconstructive Surgery
Related National Coverage Documents
250.4 - Treatment of Actinic Keratosis
Public Versions
Updated On Effective Dates Status
09/22/2021 11/14/2021 - N/A Currently in Effect You are here