Position Statement Treatments that primarily affect the appearance are considered medically necessary only in the following circumstances:
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1 Policy Name: Cosmetic Services Policy Number: CMO 500 Effective Date of current policy: 9/1/2018 Description and Scope This policy applies to procedures that primarily affect the appearance of the member. Specific policies that should be consulted include: MCG Mastectomy for Gynecomastia, MCG Reduction, Mammoplasty MCG Abdominoplasty, MCG Panniculectomy, MCG Rhinoplasty MCG Sclerotherapy, Leg Veins MCG Blepharoplasty, Canthoplasty, and Related Procedures, Affinity Medical Policy on Gender Dysphoria This policy does not apply to Medicare Advantage members. Position Statement Treatments that primarily affect the appearance are considered medically necessary only in the following circumstances: 1. The reason for the treatment is to correct a significant congenital defect or anomaly that is beyond normal human variation. An example of this is laser therapy for a significant port wine stain on the face, or 2. The reason for the treatment is reconstructive; that is, correcting an abnormal appearance due to injury, disease, or treatment. An example of this is breast reconstruction following mastectomy, or 3. The treatment is part of a medically necessary procedure. An example of this is tattooing to allow for radiation therapy, or 4. Genitalia or breast surgery for members with gender dysphoria. Please see Policy: Gender Reassignment Surgery for details and for medical necessity criteria. Cosmetic treatments are usually not considered eligible for coverage. This includes, but is not limited to, treatments, drugs, products, hospital/facility charges, anesthesia, pathology/lab fees, radiology fees and professional fees by the surgeon, assistant surgeon, consultants and attending physicians. Background Therapy to change appearance is commonplace. Unwanted hair is treated with creams, medications, electrolysis, and lasers. Baldness is treated with creams and oral medications. Wrinkles, acne scars, uneven pigmentation, thin lips, and aging skin are treated with creams, dermal fillers, lasers, and botulinum toxin. An unprepossessing jawline is treated with genioplasty. Spider veins (telangiectasia) are treated with lasers or a sclerosing solution. Some people have liposuction, treatment of inverted nipples, or removal of accessary nipples. These treatments are considered cosmetic and not medically necessary, except as noted above.
2 Certain treatments may be medically necessary or cosmetic depending upon the circumstances. Chemical peels are medically necessary when used to treat pre-malignant lesions that have not responded to standard topical and oral therapies. Some examples of cosmetic and not medically necessary treatments include (but are not limited to): Chemical peels, including for treatment of acne, acne scars, or pigmentation, cpt codes and Dermabrasion for treatment of acne, acne scars, or pigmentation, cpt codes Ear piercing and repair of a pierced earlobe or pierced body part. Breast augmentation (when not used to treat gender dysphoria) Treatment of diastasis recti Definitions Cosmetic Services are services whose primary function is to change an appearance which is within normal human anatomic variation. Accessory nipples, acne scars, and irregular pigmentation are examples of normal human anatomic variation. Common anticipated side effects of cosmetic surgery (for example, nausea and vomiting that results in a hospital stay) are considered part of the cosmetic surgery procedure. Surgery needed to improve the function of an abnormal body part is not considered cosmetic. Reconstructive surgery is surgery intended to restore appearance that is abnormal because of congenital anomalies (for example, cleft lip), trauma, disease, or its treatment. Surgery to correct an unpleasing outcome from cosmetic surgery is not considered reconstructive. Coding Inclusion of a code in the following list does not imply that the procedure is medically necessary or that the code represents a covered benefit. Codes used to identify services associated with this policy may include (but may not be limited to) the following: Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions Removal of skin tags; each additional 10 lesions Subcutaneous injection of filling material (eg, collagen); 1 cc or less Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc Subcutaneous injection of filling material (eg, collagen); over 10.0 cc Punch graft for hair transplant; 1 to 15 punch grafts Punch graft for hair transplant; more than 15 punch grafts Dermabrasion; total face (e.g. for acne scarring, fine wrinkling, rhytids, general keratosis) Dermabrasion, segmental, face Dermabrasion, regional, other than face Dermabrasion, superficial, any site, (eg, tattoo removal) Abrasion; single lesion (eg, keratosis, scar)
3 15787 Abrasion; each additional four lesions or less Chemical peel, facial; epidermal Chemical peel, facial; dermal Chemical peel; total face Chemical peel; face, hand or elsewhere Chemical peel, nonfacial; epidermal Chemical peel, nonfacial; dermal Salabrasion; 20 sq cm or less Salabrasion; over 20 sq cm Cervicoplasty Blepharoplasty, lower eyelid; Blepharoplasty, lower eyelid; with extensive herniated fat pad Rhytidectomy; forehead Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) Rhytidectomy; glabellar frown lines Rhytidectomy; cheek, chin, and neck Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap Excision, excessive skin and subcutaneous tissue (including lipectomy); thigh Excision, excessive skin and subcutaneous tissue (including lipectomy); leg Excision, excessive skin and subcutaneous tissue (including lipectomy); hip Excision, excessive skin and subcutaneous tissue (including lipectomy); buttock Excision, excessive skin and subcutaneous tissue (including lipectomy); arm Excision, excessive skin and subcutaneous tissue (including lipectomy); forearm or hand Excision, excessive skin and subcutaneous tissue (including lipectomy); submental fat pad Excision, excessive skin and subcutaneous tissue (including lipectomy); other area Suction assisted lipectomy; head and neck Suction assisted lipectomy; trunk Suction assisted lipectomy; upper extremity Suction assisted lipectomy; lower extremity Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm Cryotherapy (CO2 slush, liquid N2) for acne Chemical exfoliation for acne (eg, acne paste, acid) Electrolysis epilation, each ½ hour Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions Mastopexy Correction of inverted nipples Genioplasty; augmentation (autograft, allograft, prosthetic material) Genioplasty; sliding osteotomy, single piece Genioplasty; sliding osteotomies, 2 or more osteotomies (e.g., wedge excision or bone wedge reversal for asymmetrical chin) Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)
4 21125 Augmentation, mandibular body or angle; prosthetic material Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip Rhinoplasty, primary; including major septal repair Rhinoplasty, secondary; minor revision (small amount of nasal tip work) Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); face Injection of sclerosing solution; single vein Injection of sclerosing solution; multiple veins, same leg Ear piercing Otoplasty, protruding ear, with or without size reduction S0800 Laser in situ keratomileusis S0810 Photorefractive keratectomy S0812 Phototherapeutic keratectomy Keratomileusis Keratophakia Epikeratoplasty Radial keratotomy Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia) Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach Repair of blepharoptosis; (tarso) levator resection or advancement, external approach Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) Repair of blepharoptosis; conjunctivo-tarso-muller's muscle-levator resection (eg, Fasanella- Servat type) References New York State Insurance Department. Regulation 183 (11 NYCRR 56) Health Insurance Claims and Procedure Specialty matched clinical peer review. Medical Policy Committee History and Revisions Date Action July 24, 2018 Initial approval by Medical Policy and Benefits Committee
5 Disclaimer Affinity Health Plan has developed medical policies that serve as one of the sets of guidelines for coverage decisions. Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the medical policies. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law. Medical policy does not constitute plan authorization, nor is it an explanation of benefits. The policies are not medical advice. Affinity Health Plan reserves the right to change medical policies.
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