According to the American Society of Plastic Surgeons, the specialty of plastic surgery includes reconstructive surgery and cosmetic surgery.
According to the American Society of Oral and Maxillofacial Surgeons, the specialty includes facial reconstruction.
Reconstructive surgery is performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, surgery, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.
Cosmetic surgery is performed to reshape normal structures of the body to improve the patient's appearance and self-esteem.
Cosmetic surgery performed purely for the purpose of enhancing one's appearance is not eligible for coverage.
However, surgery to correct congenital defects, developmental abnormalities, trauma, infections, tumors or disease may be covered, because the surgery is considered reconstructive in nature.
Cosmetic surgery performed to treat psychiatric or emotional problems is generally not covered.
Corrective facial surgery will be considered cosmetic, rather than reconstructive, when there is no functional impairment present. However, some congenital, acquired, traumatic or developmental anomalies may not result in functional impairment, but are so severely disfiguring as to merit consideration for corrective surgery, e.g., craniofacial anomalies associated with Treacher Collins syndrome may be considered on an individual basis.
If a non-covered cosmetic surgery is performed in the same operative period as a covered surgical procedure, benefits will be provided for the covered surgical procedure only.
Benefits are provided for complications arising from cosmetic surgery, as long as infection, hemorrhage or other serious documented medical complication occurs and the beneficiary has been officially discharged from the facility.
Payment will be made for the following procedures when performed for the reasons indicated:
Group 1: Dermabrasion
Coverage will be provided when correcting defects resulting from traumatic injury, surgery or disease. Dermabrasion performed for post-acne scarring is classified as cosmetic and is not covered for payment.
Group 2: Abdominal Lipectomy/Panniculectomy
Abdominal lipectomy/panniculectomy is surgical removal of excessive fat and skin from the abdomen. When surgery is performed to alleviate such complicating factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigo dermatitis, such surgery is considered reconstructive. Preoperative photographs may be required to support justification and should be supplied upon request.
Palmetto GBA considers panniculectomy medically necessary when the panniculus hangs below the level of the pubis, and the medical records document that the panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs over 3 months while receiving appropriate medical therapy, or remains refractory to appropriate medical therapy over a period of 3 months.
Palmetto GBA considers panniculectomy experimental and investigational for minimizing the risk of hernia formation or recurrence. There is no adequate evidence that pannus contributes to hernia formation. The primary cause of hernia formation is an abdominal wall defect or weakness, not a pulling effect from a large or redundant pannus.
Note: If the procedure is being performed following significant weight loss, in addition to meeting the criteria noted above, there should be evidence that the individual has maintained a stable weight for at least 3 to 6 months. If the weight loss is the result of bariatric surgery, abdominoplasty/panniculectomy should generally not be performed until at least 18 months after bariatric surgery and only when weight has been stable for at least the most recent 3 to 6 months.
Palmetto GBA does not cover abdominoplasty or panniculectomy when performed primarily for any of the following indications, because it is considered not medically necessary (this list may not be all-inclusive):
- Treatment of neck or back pain
- Improving appearance (i.e., cosmesis)
- Repairing abdominal wall laxity or diastasis recti
- Treating psychological symptomatology or psychosocial complaints
- When performed in conjunction with abdominal or gynecological procedures (e.g., abdominal hernia repair, hysterectomy, obesity surgery) unless criteria for panniculectomy and abdominoplasty are met separately
Group 3: Reconstructive Breast Surgery; Removal of Breast Implants
For a patient who has had an implant(s) placed for reconstructive or cosmetic purposes, Medicare considers treatment of any 1 or more of the following conditions to be medically necessary:
- Broken or failed implant
- Implant extrusion
- Siliconoma or granuloma
- Interference with diagnosis of breast cancer
- Painful capsular contracture with disfigurement
Group 4 and 5: Reduction Mammoplasty
Macromastia (breast hypertrophy) is disproportionate volume and weight of breast tissue relative to the general body habitus. Breast hypertrophy may adversely affect other body systems (e.g., musculoskeletal, respiratory, integumentary). Unilateral hypertrophy may result in symptoms following contralateral mastectomy.
Reduction mammoplasty is performed:
- To reduce the size of the breasts and help ameliorate symptoms caused by hypertrophy
- To reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery
Medicare medical necessity for reduction mammoplasty is limited to circumstances in which:
- There are signs and/or symptoms resulting from the enlarged breasts (macromastia) that have not responded adequately to non-surgical interventions
- To improve symmetry following cancer surgery on one breast
NOTE: For coverage indications for contralateral reconstruction of an unaffected breast following a medically necessary mastectomy, refer to the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §140.2.
Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit. Cosmetic signs and/or symptoms would include ptosis, poorly fitting clothing and beneficiary perception of unacceptable appearance.
Non-surgical interventions preceding reduction mammoplasty should include as appropriate, but are not limited to, the following:
- Determining the macromastia is not due to an active endocrine or metabolic process
- Determining the symptoms are refractory to appropriately fitted supporting garments, or following unilateral mastectomy, persistent with an appropriately fitted prosthesis or reconstruction therapy at the site of the absent breast
- Determining that dermatologic signs and/or symptoms are refractory to, or recurrent following, a completed course of medical management
For Medicare purposes, a reasonable and necessary reduction mammoplasty could be indicated in the presence of significantly enlarged breasts and the presence of at least 1 of the following signs and/or symptoms:
- Back pain from macromastia, unrelieved by:
- Conservative analgesia
- Supportive measures (garment, etc.)
- Physical therapy
- Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity
- Intertriginous maceration or infection of the inframammary skin refractory to dermatologic measures
- Shoulder grooving with skin irritation by supporting garment (bra strap)
Considerable attention has been given to the amount of breast tissue removed in differentiating between cosmetic and medically necessary reduction mammoplasty. Arbitrary minimum weight breast tissue removed criteria do not consistently reflect the consequences of mammary hypertrophy in individuals with a unique body habitus. There are wide variations in the range of height, weight and associated breast size that cause symptoms. The amount of tissue that must be removed to relieve symptoms will vary and depend upon these variations. The following are guidelines (not rules) that address the patient’s weight and the amount of breast tissue removed:
- 95-119 lbs. 300 grams excised per breast
- 110-130 lbs. 400 grams excised per breast
- 130+ lbs. 500 grams excised per breast
Medicare coverage of reduction mammoplasty is limited to those circumstances where the medical record supports the following:
- The signs and/or symptoms have been present for at least 6 months
- Medical treatment and/or physical interventions have not adequately alleviated symptoms
Group 6: Rhinoplasty
Nasal surgery is defined as any procedure performed on the external or internal structures of the nose, septum or turbinate. This surgery may be performed to improve abnormal function, reconstruct congenital or acquired deformities, or to enhance appearance. It generally involves rearrangement or excision of the supporting bony and cartilaginous structures and incision or excision of the overlying skin of the nose.
Nasal surgery, including rhinoplasty, may be reconstructive or cosmetic in nature. Current CPT® codes do not allow distinction of cosmetic or reconstructive procedures by specific codes; therefore, categorization of each procedure is to be distinguished by the presence or absence of specific signs and/or symptoms.
Cosmetic Nasal Surgery
When nasal surgery is performed solely to improve the patient's appearance in the absence of any signs and/or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and noncovered under the Medicare program.
Reconstructive Nasal Surgery
When nasal surgery, including rhinoplasty, is performed to improve nasal respiratory function, correct anatomic abnormalities caused by birth defects or disease, or revise structural deformities produced by trauma, the procedure should be considered reconstructive.
Palmetto GBA covers rhinoplasty as medically necessary when there is photographic documentation (all of the following: frontal, lateral and worm’s eye view) of the individual’s condition, and the procedure is performed for correction or repair of any of the following:
- Nasal deformity secondary to a cleft lip/palate or other congenital craniofacial deformity causing a functional impairment
- Chronic, nonseptal, nasal obstruction due to vestibular stenosis (i.e., collapsed internal valves)
- Secondary to trauma, disease, congenital defect with nasal airway obstruction unresponsive to a recent trial of conservative medical management lasting at least six weeks that has either not resolved after previous septoplasty/turbinectomy or would not be expected to resolve with septoplasty/turbinectomy alone
Palmetto GBA does not cover rhinoplasty when performed for either of the following indications because it is considered cosmetic in nature or not medically necessary:
- Solely for the purpose of changing appearance
- As a primary treatment for an obstructive sleep disorder when the above criteria for approval have not been met
Palmetto GBA covers septoplasty as medically necessary when performed for any of the following indications:
- Septal deviation causing nasal airway obstruction that has proved unresponsive to a recent trial of conservative medical management lasting at least 6 weeks
- Recurrent sinusitis secondary to a deviated septum that does not resolve after appropriate medical and antibiotic therapy
- Recurrent epistaxis related to a septal deformity
- Asymptomatic septal deformity that prevents access to other transnasal areas when such access is required to perform medically necessary procedures (e.g., ethmoidectomy)
- Performed in association with cleft lip or cleft palate repair
- Obstructed nasal breathing due to septal deformity or deviation that has proved unresponsive to medical management and is interfering with the effective use of medically necessary Continuous Positive Airway Pressure (CPAP) for the treatment of an obstructive sleep disorder
Reconstructive nasal surgery is generally directed to improve nasal respiratory function (e.g., airway obstruction or stricture, synechiae formation); repair defects caused by trauma (e.g., nasoseptal deviation, intranasal cicatrix, dislocated nasal bone fractures, turbinate hypertrophy); treat congenital anatomic abnormalities (e.g., cleft lip nasal deformities, choanal atresia, oronasal or oromaxillary fistula); treat nasal cutaneous disease (e.g., rhinophyma, dermoid cyst); or to replace nasal tissue lost after tumor ablative surgery.
Group 7: Oral Maxillofacial Prosthesis
A mandibular resection prosthesis is indicated when a portion of the mandible is missing or removed due to trauma or ablative surgery. Other prostheses, such as orbital and auricular, may also be needed following this type of surgery and will be covered on the basis of this LCD's limited coverage. Interim restorative supports, such as oral surgical splints and obturator prostheses, will be covered within the setting of a comprehensive and documented treatment plan. Maxillary and mandibular prostheses are frequently necessary for the restoration of function, as neither function in the absence of an opposing surface.
Implants, which could be considered dental but are being inserted to secure, attach, or support the maxillofacial prosthesis, will be covered when the prosthesis is to be used secondary to maxillofacial surgery or repair of traumatic injury.
Compliance with the provisions in this policy is subject to monitoring by postpayment data analysis and subsequent medical review.
LCD Individual Consideration
Corrective facial surgery will be considered cosmetic, rather than reconstructive, when there is no functional impairment present. However, some congenital, acquired, traumatic or developmental anomalies may not result in functional impairment, but are so severely disfiguring as to merit consideration for corrective surgery. For example, the craniofacial anomalies associated with Treacher Collins syndrome should be reviewed on an individual consideration basis.