MEDICAL POLICY Cosmetic and Reconstructive Surgery

Transcription

1 POLICY PG-0104 EFFECTIVE /15/08 LAST REVIEW... 01/10/17 MEDICAL POLICY Cosmetic and Reconstructive Surgery GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement. DESCRIPTION Cosmetic services are defined as services which are used to improve a person's appearance, but not their functionality. Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem. Their condition is not impairing their ability to participate in daily activities and routines. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. POLICY Cosmetic procedures are non-covered. Some reconstructive procedures require prior authorization. A provider must refer to the Paramount prior authorization list and specific medical policy in reference to specific procedures (this list may not be allinclusive): PG0007 Blepharoplasty, Reconstructive Eyelid Surgery, and Brow Lift PG0009 Rhinoplasty PG0012 Breast Implant Removal PG0054 Reduction Mammoplasty PG0091 Treatment of Spider Veins PG0105 Benign Skin Lesion Removal PG0144 Breast Reconstructive Services PG0162 Excimer Laser PG0163 Bariatric Services PG0199 Keratoprosthesis PG0221 Mastectomy for Gynecomastia PG0226 Orthognathic Surgery PG0251 Prophylactic Mastectomy PG0256 Penile Implant Surgical Services and Prosthesis PG0289 Refractive Surgery PG0299 Abdominoplasty, Panniculectomy and Liposuction PG0308 Pulsed Dye Laser Therapy for Cutaneous Vascular Lesions PG0311 Gender Reassignment Surgery PG0348 Acne Treatments PG0376 Otoplasty For codes not in another specific medical policy: HMO, PPO, Individual Marketplace Procedures 15775, 15776, 15786, 15787, 15819, 15824, 15825, 15826, 15828, 15829, 15876, 15878, 15879, 17380, 21137, 21138, 21139, 21172, 21175, 21179, 21180, 21256, 21260, 21261, 21263, 21267, 21268, 21280, 21282, 30120, 69090, C9800, G0429, L8607, Q2026, & Q2028 are non-covered Advantage Procedures 15876, 15878, & require a prior authorization.

2 Procedures 15786, 15787, 21137, 21138, 21139, 21172, 21175, 21179, 21180, 21256, 21260, 21261, 21263, 21267, 21268, 21280, 21282, & do not require a prior authorization. Procedures 15775, 15776, 15819, 15824, 15825, 15826, 15828, 15829, 17380, 69090, C9800, G0429, L8607, Q2026, & Q2028 are non-covered Elite Procedures 15828, 15829, C9800, G0429, Q2026, & Q2028 do not require a prior authorization. Procedures 15775, 15776, 15786, 15787, 15819, 15824, 15825, 15826, 15876, 15878, 15879, 17380, 21137, 21138, 21139, 21172, 21175, 21179, 21180, 21256, 21260, 21261, 21263, 21267, 21268, 21280, 21282, 30120, 69090, & L8607 are non-covered. There are diagnoses that indicate services that are performed for cosmetic indications. The services may not usually be defined as cosmetic except when medically supported by the specific cosmetic diagnosis attached to the procedure. These diagnoses, when reported as the primary diagnosis (in the first diagnosis field), will cause the related service to be denied as cosmetic. Evaluation and management (E/M) services ( ) will not be denied as cosmetic when billed with these diagnoses. Only the actual surgical, radiology, pathology, laboratory, and medicine services provided will be denied when performed for cosmetic indication. The E/M service is a medical necessity for review/determination, and therefore provider reimbursement is warranted. The following diagnosis codes have been identified to be cosmetic services and will always be denied: ICD-9-CM CODES Adjustment reaction with prolonged depressive reaction V50.0 Elective hair transplant for purposes other than remedying health states V50.1 Other plastic surgery for unacceptable cosmetic appearance V50.3 Ear piercing V50.8 Other elective surgery for purposes other than remedying health states V50.9 Unspecified elective surgery for purposes other than remedying health states ICD-10-CM CODES; EFFECTIVE 10/01/2015 F43.21 Adjustment disorder with depressed mood Z40.8 Encounter for other prophylactic surgery Z40.9 Encounter for prophylactic surgery, unspecified Z41.1 Encounter for cosmetic surgery Z41.3 Encounter for ear piercing Z41.8 Encounter for other procedures for purposes other than remedying health state Z41.9 Encounter for procedure for purposes other than remedying health state, unspecified A provider must refer to the Paramount prior authorization list and specific medical policy in reference to specific procedures. There are certain reconstructive services that require prior authorization for reimbursement. These services will be reviewed for medical necessity to ensure they do not fall within the guidelines of cosmetic services. If the service is allowed with prior authorization but is denied because prior authorization was refused, the service will be denied and the member cannot be held financially liable. Paramount members may be eligible for reconstructive surgery under the Plan when a functional impairment is present, and supporting language is contained in the member s contract for either of the following indications: 1. The procedure is intended primarily to improve/restore bodily function or to correct significant deformity resulting from accidental injury, trauma, or previous therapeutic process OR 2. The procedure is intended to correct congenital or developmental anomalies that have resulted in significant functional impairment. Paramount does not cover investigational, cosmetic or not medically necessary services and will not reimburse for any services, procedures, drugs or supplies associated with those investigational, cosmetic or not medically necessary services. Psychiatric and/or emotional distress are not considered medically necessary indications for cosmetic procedures.

3 If documentation is requested, it should include the following: 1. Medical records indicating that the procedure will be or was performed to restore/improve bodily function or to correct deformity resulting from accidental injury, trauma, or previous therapeutic process. In the absence of this documentation, the surgery or procedure must be considered cosmetic 2. Photographs 3. Copies of consultations 4. Operative reports 5. Any other pertinent information Paramount may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included. HMO, PPO, Individual Marketplace Some reconstructive procedures require prior authorization. A provider must refer to the Paramount prior authorization list and specific medical policy in reference to specific procedures Cosmetic services are non-covered and if performed the member is financially responsible. Advantage Some reconstructive procedures require prior authorization. A provider must refer to the Paramount prior authorization list and specific medical policy in reference to specific procedures For Advantage members, the provider must obtain a waiver of financial liability from the member, per Medicaid guidelines, prior to the performance of a designated reconstructive service that does not require prior authorization. All cosmetic services are non-covered and will be denied as provider s liability regardless of whether the member has signed a written notice or not. Advantage members may appeal their financial responsibility for the procedure ONLY if: The provider failed to obtain the waiver of financial liability prior to performing the procedure. The claim will be adjusted to deny back to the provider. There is medical necessity supporting the performance of the service per medical criteria set by Paramount for the service. For procedures determined to be non-covered, Advantage members must sign a waiver of financial liability. Failure to do so will result in a denial of financial responsibility from the member to the provider. LIPECTOMY (15876, 15878, 15879) While there is insufficient evidence in the published medical literature to demonstrate the safety, efficacy and longterm outcomes of lipectomy, The Ohio Department of Medicaid requires this procedure be reviewed for medical necessity. Therefore it may be covered with a prior authorization for Advantage members. Elite Some reconstructive procedures require prior authorization. A provider must refer to the Paramount prior authorization list and specific medical policy in reference to specific procedures For Elite members, the provider must obtain a completed ABN from the member, per Medicare guidelines, prior to the performance of the designated cosmetic procedure that does not require a prior authorization. Elite members may appeal their responsibility for the procedure ONLY if: The provider failed to obtain the ABN prior to performing the procedure. The claim will be adjusted to deny back to the provider. There is medical necessity supporting the performance of the service per medical criteria set by Paramount for the service. For procedures determined to be non-covered, Elite members must sign an ABN. Failure to do so will result in a denial of financial responsibility from the member to the provider.

4 CODING/BILLING INFORMATION The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered. CODE DESCRIPTION MEDICAL POLICY Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions PG Removal of skin tags, multiple fibrocutaneous tags, any area; each additional ten lesions (List separately in PG0105 addition to code for primary procedure) Shaving of epidermal or dermal lesions PG Excision of benign lesions PG Intradermal tattooing; 6sq cm or less PG Intradermal tattooing; 6.1 to 20sq cm PG Intradermal tattooing; each additional 20sq cm or part thereof PG Subcutaneous injection of filling material (e.g., collagen); 1 cc or less PG Subcutaneous injection of filling material (e.g., collagen); 1.1 to 5.0cc PG Subcutaneous injection of filling material (e.g., collagen); 5.1 to 10.0cc PG Subcutaneous injection of filling material (e.g., collagen); over 10.0cc PG Replacement of tissue expander with permanent prosthesis PG Removal of tissue expander(s) without insertion of prosthesis PG Punch graft for hair transplant; 1 to 15 punch grafts Punch graft for hair transplant; more than 15 punch grafts Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis) PG Dermabrasion; segmental, face PG Dermabrasion; regional, other than face PG Dermabrasion; superficial, any site (eg, tattoo removal) PG Abrasion; single lesion (eg, keratosis, scar) Abrasion; each additional 4 lesions or less (List separately in addition to code for primary procedure) Chemical peel, facial; epidermal PG Chemical peel, facial; dermal PG Chemical peel, nonfacial; epidermal PG Chemical peel, nonfacial; dermal PG Cervicoplasty Blepharoplasty, lower lid PG Blepharoplasty, lower eyelid; with extensive herniated fat pad PG Blepharoplasty, upper lid PG Blepharoplasty, upper eyelid; with excessive skin weighting down lid PG Rhytidectomy; forehead Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) Rhytidectomy; glabellar frown lines Rhytidectomy; cheek, chin, neck Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy PG Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen PG Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh PG Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg PG Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip PG Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock PG Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm PG Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm/hand PG Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad PG Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area PG Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen (eg, abdominoplasty) PG0299 (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) Suction assisted lipectomy; head/neck Suction assisted lipectomy; trunk PG Suction assisted lipectomy; upper extremity Suction assisted lipectomy; lower extremity Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant PG0105 lesions (eg, actinic keratoses); first lesion Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant PG0105

5 lesions (eg, actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion) Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant PG0105 lesions (eg, actinic keratoses), 15 or more lesions Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm PG Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm PG Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm PG Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign PG0105 lesions other than skin tags or cutaneous vascular lesions; up to 14 lesions Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign PG0105 lesions other than skin tags or cutaneous vascular lesions; 15 or more lesions Cryotherapy (CO, slush, liquid N ) for acne PG Chemical exfoliation for acne (e.g., acne paste, acid) PG Electrolysis epilation, each 30 minutes Mastectomy for gynecomastia PG Partial mastectomy (i.e., lumpectomy) PG Partial mastectomy with lymphadenectomy PG Simple complete mastectomy PG Subcutaneous mastectomy PG Radical mastectomy including pectoral muscles, axillary lymph nodes PG Radical mastectomy including pectoral muscles, axillary and internal mammary lymph nodes (urban type) PG Modified radical mastectomy with or without pectoralis minor muscles, axillary lymph nodes but excluding PG0251 pectoralis major muscle Mastoplexy PG Reduction mammoplasty PG Augmentation mammaplasty without prosthetic implant PG Augmentation mammaplasty with prosthetic implant PG Removal of intact mammary implant PG Removal of mammary implant material PG Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction PG Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction PG Nipple/areole reconstruction PG Correction of inverted nipples PG Breast reconstruction (immediate or delayed) with tissue expander, including subsequent expansion PG Breast reconstruction with latissimus dorsi flap without prosthetic implant PG Breast reconstruction with free flap PG Breast reconstruction with other technique PG Breast reconstruction with transverse rectus abdominis myocutaneous (tram), single pedicle, including closure PG0144 of the donor site Breast reconstruction with transverse rectus abdominis myocutaneous (tram), single pedicle with microvascular PG0144 anastomosis (supercharging) Breast reconstruction with transverse rectus abdominis myocutaneous (tram), double pedicle, including closure PG0144 of the donor site Open periprosthetic capsulotomy, breast PG Periprosthetic breast capsulectomy PG Revision of reconstructed of breast PG Preparation of moulage for custom breast implant PG Genioplasty; augmentation PG Genioplasty; sliding osteotomy PG Genioplasty; sliding osteotomies PG Genioplasty; sliding augmentation PG Augmentation, mandibular body or angle; prosthetic material PG Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) PG Reduction forehead; contouring only Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) Reduction forehead; contouring and setback of anterior frontal sinus wall Reconstruction midface, LeFort I; single piece, segment movement in any direction (e.g., for Long Face PG0226 Syndrome), without bone graft Reconstruction midface, LeFort I; two pieces, segment movement in any direction, without bone graft PG Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, without bone graft PG Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) PG0226

6 21146 Reconstruction midface, LeFort I; two pieces, segment movement in any direction, requiring bone grafts PG0226 (includes obtaining autografts) (e.g., ungrafted unilateral alveolar cleft) Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, requiring bone PG0226 grafts (includes obtaining autografts) (e.g., ungrafted bilateral alveolar cleft or multiple osteotomies) Reconstruction midface, LeFort II; anterior intrusion (e.g., Treacher-Collins Syndrome) PG Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts) PG Reconstruction midface, LeFort III; (extracranial), any type, requiring bone grafts (includes obtaining autografts); PG0226 without LeFort I Reconstruction midface, LeFort III; (extracranial), any type, requiring bone grafts (includes obtaining autografts); PG0226 with LeFort I Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring PG0226 bone grafts (includes obtaining autografts); without LeFort I Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring PG0226 bone grafts (includes obtaining autografts); with LeFort I Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts) Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts) Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material) Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts) Reconstruction by contouring of benign tumor of cranial bones (e.g., fibrous dysplasia), extracranial PG Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of PG0226 benign tumor of cranial bone (e.g., fibrous dysplasia) with multiple autografts (includes obtaining grafts); total area of bone grafting less than 40 sq cm Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of PG0226 benign tumor of cranial bone (e.g., fibrous dysplasia) with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 40 sq cm but less than 80 sq cm Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of PG0226 benign tumor of cranial bone (e.g., fibrous dysplasia) with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 80 sq cm Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) PG Reconstruction of mandible rami; horizontal, vertical, C, or L osteotomy; without bone graft PG Reconstruction of mandible rami; horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining PG0226 graft) Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation PG Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation PG Osteotomy, mandible, segmental PG Osteotomy mandible; w/ advancement PG Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard) PG Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) PG Osteoplasty, facial bones; reduction PG Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) PG Graft, bone; mandible (includes obtaining graft) PG Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) PG Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) PG Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) PG Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate) PG Reconstruction of mandible or maxilla, subperiosteal implant; partial PG Reconstruction of mandible or maxilla, subperiosteal implant; complete PG Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (e.g., for PG0226 hemifacial microsomia) Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial PG Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete PG Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) PG Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia) Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and extracranial approach Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and extracranial approach

7 21270 Malar augmentation, prosthetic material PG Secondary revision of orbitocraniofacial reconstruction PG Medial canthopexy (separate procedure) Lateral canthopexy Reduction of masseter muscle and bone (e.g., for treatment of benign masseteric hypertrophy); extraoral PG0226 approach Reduction of masseter muscle and bone (e.g., for treatment of PG0226 benign masseteric hypertrophy); intraoral approach Reconstructive repair of pectus excavatum or carinatum PG Excision or surgical planning of skin of nose for rhinophyma Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip PG Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or PG0009 elevation of nasal tip Rhinoplasty, primary; including major septal repair PG Rhinoplasty, secondary; minor revision (small amount of nasal tip work) PG Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) PG Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) PG Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; PG0009 tip only Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; PG0009 tip, septum, osteotomies Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction) PG Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk PG Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy PG0163 (roux limb 150 cm or less) Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to PG0163 limit absorption Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g., PG0163 gastric band and subcutaneous port components) Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component PG0163 only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component PG0163 only Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive PG0163 device component only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and PG0163 subcutaneous port components Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy) PG Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical banded gastroplasty PG Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical banded gastroplasty PG Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoileostomy PG0163 (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150cm or less) Roux-en-Y PG0163 gastroenterostomy Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit PG0163 absorption Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device PG0163 (separate procedure) Gastric restrictive procedure, open; revision of subcutaneous port component only PG Gastric restrictive procedure, open; removal of subcutaneous port component only PG Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only PG Insertion of penile prosthesis; noninflatable (semi-rigid) PG Insertion of penile prosthesis; inflatable (self-contained) PG Insertion of multi-component inflatable penile prosthesis, including placement of pump, cylinders and reservoir PG Removal and replacement of all components of a multicomponent penile prosthesis at the same operative PG0256 session Removal and replacement of all components of a multicomponent penile prosthesis at the same operative PG0256 session, including irrigation/debridement of infected tissue Removal and replacement of non-inflatable or inflatable penile prosthesis at the same operative session PG Removal and replacement of non-inflatable or inflatable penile prosthesis at the same operative session, PG0256 including irrigation/debridement of infected tissue insertion of testicular prosthesis PG0311

8 55970 Intersex surgery; male to female PG Intersex surgery; female to male PG Keratomileusis PG Keratophakia PG Epikeratoplasty PG Keratoprosthesis PG Radial keratotomy (RK) PG Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) PG Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) PG Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia) PG Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach PG Repair of blepharoptosis; (tarso) levator resection or advancement, external approach PG Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) PG Repair of blepharoptosis; conjunctivo-tarso-muller's muscle-levator resection (eg, Fasanella-Servat type) PG Reduction of overcorrection of ptosis PG Correction of lid retraction PG Ear piercing Otoplasty, protruding ear, with or without size reduction PG Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm PG Laser treatment for inflammatory skin disease (psoriasis); 250 sq cm to 500 sq cm PG Laser treatment for inflammatory skin disease (psoriasis); over 500 sq cm PG0162 C9800 Dermal injection procedure(s) for facial lipodystrophy syndrome (lds) and provision of radiesse or sculptra dermal filler, including all items and supplies G0429 Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (lds) (e.g., as a result of highly active antiretroviral therapy) L8600 Implantable breast prosthesis, silicone or equal PG0144 L8607 Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies Q2026 Injection, radiesse, 0.1 ml Q2028 Injection, sculptra, 0.5 mg S0800 Laser in-situ keratomileusis (Lasik) PG0289 S0810 Photorefractive keratectomy (PRK) PG0289 S0812 Phototherapeutic keratectomy (PTK) PG0289 S2066 Breast reconstruction with gluteal artery perforator (gap) flap, inc harvesting of flap, microvascular transfer, PG0144 closure of donor site/shaping the flap into breast, unilateral S2067 Breast reconstruction of a single breast with "stacked" deep inferior epigastric perforator (DIEP) flap(s) and/or PG0144 gluteal artery perforator (gap) flap(s), inc harvesting of flap(s), microvascular transfer, closure of donor site(s)/shaping flap into breast, unilateral S2068 Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery PG0144 (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral S2083 Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline PG0163 REVISION HISTORY EXPLANATION 01/28/11: E/M services will be reimbursed when submitted with specific codes that are considered cosmetic per medical policy review. 07/22/11: Per the Medical Policy Steering Committee review and determination, diagnosis code keloid scar, will be removed from the listed cosmetic diagnosis services. All product lines. 09/08/15: Changed title from Cosmetic Services to Cosmetic and Reconstructive Surgery. Removed ICD-9 codes V51.8, , , , , 701.4, 18.01, 64.5, 86.24, and Added ICD-9 codes and V50.8. ICD-10 codes added from ICD-9 conversion. CPT codes 40819, 41115, 56620, 65710, 69300, 68310, removed from this policy. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. 08/09/16: Added L8607 as non-covered for all product lines. Added code and reference to new medical policy PG0376 Otoplasty. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee. 01/10/17: Effective 01/01/17 codes 15876, 15878, are now covered with prior authorization for Advantage only per ODM guidelines. Policy reviewed and updated to reflect most current clinical evidence per Medical Policy Steering Committee.

9 REFERENCES/RESOURCES Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Ohio Department of Medicaid American Medical Association, Current Procedural Terminology (CPT ) and associated publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets Industry Standard Review Hayes, Inc.