Local Coverage Determination (LCD)

Cosmetic and Reconstructive Surgery

L33428

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L33428
Original ICD-9 LCD ID
Not Applicable
LCD Title
Cosmetic and Reconstructive Surgery
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL33428
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 07/29/2021
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
08/03/2017
Notice Period End Date
09/17/2017
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

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Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act §1862(a)(10) indicates where such expenses are for cosmetic surgery or are incurred in connection therewith, except as required for the prompt repair of accidental injury or for improvement of the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(1)(D) addresses items and services related to research and experimentation.

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §150 Dental Services and §150.1 Treatment of Temporomandibular Joint (TMJ) Syndrome

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §140.2 Breast Reconstruction Following Mastectomy and §140.4 Plastic Surgery to Correct "Moon Face"

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §250.5 Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS)

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

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

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

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
  • Infection
  • 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:

Table I

  • 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.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

For all procedures:
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to the A/B MAC upon request.

For mammoplasty:

  • The beneficiary's medical record must contain the following information, and be available for review on request:

    • Height and weight
    • Clinical evaluation of the signs and/or symptoms ascribed to the macromastia, therapies prior to reduction mammoplasty and the responses to these therapies
    • The operative report with documentation of the weight of tissue removed from each breast, obtained in the operating room
    • The pathology report of the tissue removed from each breast

 For abdominal lipectomy/panniculectomy:

  • The beneficiary's medical record must contain the following information, and be available for review on request:

    • Description of the pannis and the underlying skin
    • Description of conservative treatment undertaken and its results

For Oral and Maxillofacial Prosthesis:

    • Medical record documentation maintained by the performing provider must clearly indicate the medical necessity of the service being billed and must demonstrate the medical necessity of the services performed in excess of the established frequency guidelines. In addition, the documentation must support that the service was performed. This information is normally found in the office/progress notes, hospital records and testing results. The role of implant therapy within the total scope of the prosthetic restoration must be clearly documented.
Sources of Information

N/A

Bibliography

Reducation mammaplasty: ASPS recommended insurance coverage criteria for third-party payersAmerican Society of Plastic Surgeons. 2011. Accessed 6/22/2021.

Arthurs ZM, Cuadrado D, Sohn V, et al. Post-bariatric panniculectomy: Pre-panniculectomy body mass index impacts the complication profile. Am J Surg. 2007;193(5):567-70.

Misiek DJ, Chang AK. Implant reconstruction following removal of tumors of the head & neck. Otolaryngologic Clinics of North America. 1998;31(4):689-725.

Mosteller RD. Simplified calculation of body-surface area. N Engl J Med. 1987;317(17):1098.

Patel A, Maisel R. Condylar prostheses in head and neck cancer reconstruction. Arch Otolaryngol Head Neck Surgery. 2001;127(7):842-846.

Schnur PL, Hoehn JG, Ilstrup DM, Cahoy MJ, Chu-Pin C. Reduction mammaplasty: Cosmetic or reconstructive procedure? Ann Plast Surg. 1991;27(3):232-7.

Schnur PL. Reduction mammaplasty–The schnur sliding scale revisited. Ann Plast Surg. 1999;42(1):107-8.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
07/29/2021 R21

Under CMS National Coverage Policy updated description for regulation Title XVIII of the Social Security Act, §1862(a)(1)(D). Under Coverage Indications, Limitations and/or Medical Necessity subheading Group 7: Oral Maxillofacial Prosthesis third paragraph moved verbiage “Services billed with a diagnosis code that is not listed in the ICD-10-CM Codes That Support Medical Necessity section of this policy will be denied as not covered. Exceptions will be considered on a case-by-case basis” to the related Billing and Coding: Cosmetic and Reconstructive Surgery A56658 article. Under Associated Information subheading Documentation Requirements: For Oral and Maxillofacial Prosthesis moved verbiage “Use CPT codes only when the physician actually designs and prepares the prosthesis and not when the prosthesis is prepared by an outside laboratory,” and “When CPT codes 21089 and 21299 are billed, documentation must be submitted with the claim” to the related Billing and Coding: Cosmetic and Reconstructive Surgery A56658 article. Under Bibliography changes were made to citations to reflect AMA citation guidelines. CPT® was inserted throughout the LCD where applicable. Formatting, punctuation and typographical errors were corrected throughout the LCD.

  • Provider Education/Guidance
10/24/2019 R20

This LCD is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Cosmetic and Reconstructive Surgery A56658 article.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Provider Education/Guidance
07/04/2019 R19

All coding located in the Coding Information section has been moved into the related Billing and Coding: Cosmetic and Reconstructive Surgery A56658 article and removed from the LCD.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Provider Education/Guidance
10/01/2018 R18

Under ICD-10 Codes That Support Medical Necessity Group 7: Codes deleted C43.11, C43.12, D03.11, and D03.12. Under ICD-10 Codes That Support Medical Necessity Group 7: Codes added ICD-10 codes C43.111, C43.112, C43.121, C43.122, C4A.111, C4A.112, C4A.121, C4A.122, C44.1021, C44.1022, C44.1091, C44.1092, C44.1121, C44.1122, C44.1191,C44.1192, C44.1221, C44.1222, C44.1291, C44.1292, C44.1321, C44.1322, C44.1391, C44.1392, C44.1921, C44.1922, C44.1991, C44.1992, D03.111, D03.112, D03.121, D03.122, D04.111, D04.112, D04.121, D04.122, D23.111, D23.112, D23.121, and D23.122. This revision is due to the Annual ICD-10 Code Update and becomes effective October 1, 2018.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
05/15/2018 R17

Under ICD-10 Codes that Support Medical Necessity Group 7: Paragraph added the verbiage Medicare is establishing the following limited coverage for facial, maxillofacial and oral reconstruction and prosthetics (refer to the CPT codes as listed in the CPT/HCPCS Group 7: Paragraph). The CPT codes and following diagnoses limit the use of reconstructive surgeries of the head and neck to the repair of injuries due to trauma or ablative surgery.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
05/15/2018 R16

Under ICD-10 Codes that Support Medical Necessity Group 6: Paragraph and Group 7: Paragraph added ICD-10 codes H72.01, H72.02, H72.03, H72.2X1, H72.2X2 and H72.2X3. This revision is due to a reconsideration request and is retroactive on or after 10/01/17.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Reconsideration Request
04/06/2018 R15

Under ICD-10 Codes that Support Medical Necessity Group 6: Paragraph added CPT code 21235. Under ICD-10 Codes that Support Medical Necessity Group 7: Paragraph removed the existing verbiage and replaced with “NOTE: The CPT code and following diagnoses, limit the use of reconstructive surgeries of the head and neck to the repair of injuries due to trauma or ablative surgery”. These revisions are retroactive on or after 10/01/17.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Provider Education/Guidance
04/06/2018 R14

Under CPT/HCPCS Codes Group 6: Paragraph Rhinoplasty changed the heading to read “Group 6: Paragraph Nasal Reconstruction and Rhinoplasty”, added CPT code 21235 and added ICD-10 codes C44.212, C44.219, C44.222, C44.229, C43.21, C43.22, D03.21, D03.22, D04.21 and D04.22. Under ICD-10 Codes that Support Medical Necessity Group 7:Codes added ICD-10 codes C44.311, C44.212, C44.219, C44.321, C44.222, C44.229, C43.21, C43.22, D03.21, D03.22, D04.21 and D04.22. These revisions are due to a reconsideration request. These revisions are retroactive on or after 10/01/17.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Provider Education/Guidance
  • Reconsideration Request
02/26/2018 R13 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
01/29/2018 R12 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
01/01/2018 R11

Under Coverage Indications, Limitations and/or Medical Necessity-Group 4 and 5 Reduction Mammoplasty added verbiage related to NCD-140.2 Breast Reconstruction Following Mastectomy. This revision is due to a reconsideration request.

Under CPT/HCPCS Codes Group 7: Paragraph changed the title from “Oral and Maxillofacial Surgery” to “Facial, Maxillofacial and Oral Reconstruction and Prosthetics”. Under CPT/HCPCS Codes Group 7: Codes added CPT codes 15730 and 15733.This revision is due to the Annual CPT/HCPCS Code Update.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
  • Revisions Due To CPT/HCPCS Code Changes
  • Reconsideration Request
09/18/2017 R10

No revisions were made as no comments were received from the provider community.


 


 


 

 

  • Provider Education/Guidance
03/16/2017 R9 Revisions were made to the Cosmetic and Reconstructive Surgery local coverage determination (LCD) L33428 Under CMS National Coverage Policy - Revised sentence with Title XVIII SSA 1862 (a)(10) to start with “indicates where such expenses…” Add “Syndrome” to title for Internet Only Manual 100-04 Chapter 32 Section 260 to read “Dermal Injections for Treatment of Facial Lipodystrophy Syndrome (LDS)”.
Under Coverage Indications, Limitations and/or Medical Necessity- Grammatical correction to spelling of “intertrigal” to “intertrigo” under Abdominal Lipectomy/Panniculectomy. Correct spelling of “synechia” to “synechiae” under Reconstructive Nasal Surgery.
Under CPT/HCPCS Codes – Delete Note under Group 1: Paragraph.
Under Associated Information – Documentation Requirements- Revised wording under For mammoplasty and For abdominal lipectomy/panniculectomy to read: “The beneficiary’s medical record must contain the following information and be available for review on request”.
  • Provider Education/Guidance
  • Typographical Error
10/13/2016 R8 Under ICD-10 Codes That Support Medical Necessity-Group 4: Paragraph deleted the verbiage “Covered for…” and added the asterisk. Under ICD-10 Codes That Support Medical Necessity-Group 4: Medical Necessity ICD-10 Codes Asterisk Explanation added verbiage for clarification regarding the billing of dual diagnoses for coverage of a reduction mammoplasty. Under ICD-10 Codes That Support Medical Necessity-Group 5: Paragraph deleted the verbiage “Covered for…”.
  • Provider Education/Guidance
  • Other
10/01/2016 R7 Under Coverage Indications, Limitations and/or Medical Necessity re-numbered groups to be consistent with CPT/HCPCS coding groups. Under CPT/HCPCS Codes Group 4: Paragraph added Primary to Reduction Mammoplasty. Under CPT/HCPCS Codes added Group 5 for Reduction Mammoplasty Secondary and renumbered Rhinoplasty to Group 6. Under ICD-10 Codes That Support Medical Necessity Group 3: Codes added ICD-10 code N61.1. This revision is due to the Annual ICD-10 Code Update and becomes effective 10/1/16.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
02/25/2016 R6 Punctuation was corrected throughout the LCD. Under CMS National Coverage Policy revised the verbiage for Title XVIII of the Social Security Act, §1833(e), deleted the “s” from Manuals X4, and added the complete verbiage for CMS Internet-Only Manuals, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §140.2. Under Coverage Indications, Limitations and/or Medical Necessity-Reconstructive Nasal Surgery in the sixth paragraph revised ICD-9-CM to now read ICD-10-CM. Under CPT/HCPCS Codes added titles to each group of codes. Under ICD-10 Codes That Support Medical Necessity deleted the Note under the Group 1 Paragraph. Under Associated Information-Documentation Requirements–For abdominal lipectomy/panniculectomy corrected the spelling of “underlying” in the first bullet. Under Sources of Information and Basis for Decision corrected the website for the first citation. The title was corrected and the abbreviated journal cited was corrected to now read: Arthurs ZM, Cuadrado D, Sohn V, et al. Post Bariatric Panniculectomy: Pre-panniculectomy Body Mass Index Impacts the Complication Profile. Am J Surg. 2007;193(5):567-70. The spelling was corrected for the author name MJ Cahoy in the third cited reference. The year of publication, volume number, supplement number and page number were added for the following: Mosteller RD. Simplified Calculation of Body-Surface Area. N Engl J Med.
  • Provider Education/Guidance
  • Typographical Error
  • Other
12/10/2015 R5 Under section ICD-10 Codes that Support Medical Necessity added four ICD-10 diagnoses codes Z42.1, Z90.11, Z90.12, and Z90.13. The revision was due to a reconsideration request.
  • Provider Education/Guidance
  • Automated Edits to Enforce Reasonable & Necessary Requirements
  • Reconsideration Request
10/01/2015 R4 Under ICD-10 Codes that Support Medical Necessity Group 3: Codes, added T85.41XD, T85.41XS, T85.42XD, T85.42XS, T85.43XD, T85.43XS, T85.44XD, T85.44XS, T85.49XD, and T85.49XS.
  • Provider Education/Guidance
10/01/2015 R3 Under CMS National Coverage Policy removed Pub 100-03, Ch. 1, §140.3 Transsexual Surgery, as CMS left it up to Contractor's discretion. Sources of Information and Basis for Decision placed first bibliography citation in hyper-linked text.
  • Provider Education/Guidance
10/01/2015 R2 Under ICD-10 Codes that Support Medical Necessity removed F43.21 (Adjustment disorder with depressed mood) to the section titled ICD-10 codes that Do Not Support Medical Necessity. The ICD-10 code previously had a not applicable (NA) paragraph section that over the years through system error was removed from the paragraph section. By moving this code to the ICD-10 codes that Do Not Support Medical Necessity section of the LCD clarifies exactly that no CPT codes are applicable to this ICD-10 code.
  • Provider Education/Guidance
  • Automated Edits to Enforce Reasonable & Necessary Requirements
10/01/2015 R1 Under ICD-10 codes that Support Medical Necessity added the following ICD-10 codes to Group 6 R09.81, Group 7 ICD-10 code F43.21, and under ICD-10 codes that Do Not Support Medical Necessity added ICD-10 codes Z40.8, Z40.9, Z41.1, Z41.3, Z41.8, and Z41.9.
  • Provider Education/Guidance
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Keywords

  • COSMETIC
  • Reconstructive

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