Surgery Section - Cosmetic and Reconstructive Surgery

IMPORTANT REMINDER

This Medical Policy has been developed through consideration of medical necessity, generally accepted standards of medical practice, and review of medical literature and government approval status.

Benefit determinations should be based in all cases on the applicable contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.

The purpose of medical policy is to provide a guide to coverage. Medical Policy is not intended to dictate to providers how to practice medicine. Providers are expected to exercise their medical judgment in providing the most appropriate care.

DESCRIPTION

Cosmetic surgery is performed to reshape body structures in order to improve appearance.

POLICY/CRITERIA

Many member contracts have very specific language regarding covered reconstructive services and excluded cosmetic procedures.  Specific member contract language has precedence over medical policy, and requests for coverage of potentially cosmetic services should be reviewed by applicable member contract language. 

The following policy may be applied when member contract language is not specific:

1. If the intervention is intended to treat a functional impairment and if no other contract exclusions apply, it may be considered medically necessary.
2. If the intervention is not intended to treat a functional impairment, the cause of the condition must be determined, for example, accident/injury/trauma, post-treatment, congenital anomaly, disease.  If the cause is included in the definition of reconstructive services in the benefits contract language, then the treatment may be covered.

The following flow chart may be used as a guide to interpreting benefits language.

*See additional medical necessity criteria for the following procedures:

Blepharoplasty and Brow Ptosis Repair

Chemical Peels

Dermabrasion and Microdermabrasion

Laser Treatment for Port Wine Stain

Mastectomy for Gynecomastia

Orthognathic Surgery

Pectus Excavatum

Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants

Reduction Mammaplasty

Varicose Vein Treatment

Blepharoplasty and Brow Ptosis Repair                  Return to Flow Chart

Description

Blepharoplasty is a surgical procedure performed on the upper and/or lower eyelids to remove or repair excess tissue that obstructs the field of vision. These procedures may also be performed for cosmetic purposes in the absence of visual field obstruction.

Functional visual impairment occurs when excess upper eyelid tissue overhangs the upper eyelid margin and results in significant superior visual field obstruction.  Visual field studies are used to determine the degree of obstruction.  Visual field studies should be measured both with and without elevation of the excess tissue to determine the extent of visual field defect at rest and the amount of improvement that may be obtained from blepharoplasty. 

Policy/Criteria

1. Blepharoplasty for the following diagnoses may be considered medically necessary for an affected upper or lower lid without meeting visual loss criteria:
   1. Trichiasis
   2. Ectropion
   3. Entropion
2. In the absence of one of the conditions listed above, unilateral or bilateral upper lid blepharoplasty or levator resection may be considered medically necessary for reconstructive purposes when at least one eye meets all of the following criteria:
   1. Visual field is limited to 20 degrees or less superiorly, or limited to 10 to 15 degrees or less laterally, AND
   2. Frontal or lateral photographs demonstrate visual field limitation consistent with the visual field examination, AND
   3. Any related disease process, such as myasthenia gravis or a thyroid condition is documented as stable.
3. Brow ptosis repair may be considered medically necessary for reconstructive purposes when at least one eye meets all of the criteria for blepharoplasty above, and photographs demonstrate the eyebrow is below the supraorbital rim.
4. In order to determine medical necessity the following information will be requested:
   1. Visual fields, including physician interpretation
   2. Documentation of clinically decreased vision
   3. Lateral and full face photographs
5. Blepharoplasty in anophthalmia may be considered medically necessary when the upper eyelid position interferes with the fit of a prosthesis in the socket.
6. Blepharoplasty of the lower lids for excessive skin is considered cosmetic.

Chemical Peels (2)                                                         Return to Flow Chart

Description

A chemical peel refers to a controlled removal of varying layers of the epidermis and superficial dermis with the use of a ‘wounding’ agent, such as phenol or trichloroacetic acid (TCA). The most common indication for chemical peeling is as a treatment of photoaged skin, correcting pigmentation abnormalities, solar elastosis, and wrinkles. However, chemical peeling has also been used as a treatment for various stages of acne and multiple actinic keratoses when treatment of individual lesions is not feasible.

An epidermal peel may be used to remove fine, subtle lines, soften the appearance of enlarged pores, improve the skin texture and lighten hyper-pigmentary disorders. Multiple epidermal peels (also referred to as chemical exfoliation) may also be used in patients with active acne.

Dermal peels may be used to treat deep wrinkling, actinic damage, or actinic keratoses. Acne scarring has also been treated with dermal peels.

Policy/Criteria

Epidermal Chemical Peels

1. Epidermal chemical peels with 50 - 70% alpha hydroxy acids may be considered medically necessary to treat patients with active acne that have failed a trial of topical and/or oral antibiotic acne therapy.
2. Epidermal chemical peels for the treatment of photoaged skin, wrinkles, or acne scarring are considered cosmetic.

Dermal Chemical Peels

1. Dermal chemical peels may be considered medically necessary to treat numerous (>10) actinic keratoses or other premalignant skin lesions, when treatment of the individual lesions becomes impractical.
2. Dermal chemical peels as treatment of end-stage acne scarring are considered cosmetic.

Dermabrasion and Microdermabrasion                       Return to Flow Chart

Description

Dermabrasion uses a rapidly moving brush to remove skin and activate new skin growth.  It is commonly used for the treatment facial scars and wrinkles.

Microdermabrasion uses small microcrystals to abrade the superficial epidermal layer of the skin; suction is then used to remove any skin debris.  Microdermabrasion is often performed by estheticians for facial rejuvenation.

Policy/Criteria

1. Dermabrasion to treat photoaged skin, wrinkles, or acne scarring is considered cosmetic.
2. Microdermabrasion for the treatment of any indication is considered cosmetic.

Laser Treatment of Port Wine Stains                         Return to Flow Chart

Description

Port wine stain (PWS) is a capillary malformation that begins as a pale pink flat area (macular lesion) in childhood and grows as the patient ages. Common areas for PWS to appear are on the face over the areas of the first and second trigeminal nerves and the eyes or mouth. It is common to see a PWS overlying an arteriovenous, arterial or venous malformation. The abnormal blood vessels within the PWS become progressively more dilated in size, which results in the lesion becoming dark purple and elevated in some instances. Nodules and hypertrophy may develop in the soft tissue underlying the PWS. Nodules may continue to grow and can bleed easily if traumatized.  PWS persists into adult life and is associated with systemic abnormalities such as glaucoma.

Treatment of a PWS in its macular stage will prevent the development of the hypertrophic component of the lesion. Laser treatment of a PWS diminishes the existing blood vessels making them smaller, fewer in number, and less likely to progress in size.

Policy/Criteria

1. Laser treatment may be considered medically necessary for port wine stains.
2. Destruction of cutaneous vascular lesions for removal of telangiectasias (spider veins) is considered cosmetic.

Mastectomy for Gynecomastia                                   Return to Flow Chart

Description

Gynecomastia refers to the benign enlargement of the male breast, either due to increased adipose tissue, fibrous tissue, glandular tissue, or a combination of all three.  In some instances, adolescent gynecomastia may be reported as tender or painful, however, this pain is normally self-limiting or responds to analgesic therapy. Typically no functional impairment is associated with gynecomastia.

Policy/Criteria

Mastectomy as a treatment of gynecomastia is considered cosmetic.

Pectus Excavatum Repair                                          Return to Flow Chart

Description

Pectus excavatum, commonly referred to as "funnel chest," is a chest wall malformation in which the sternum is depressed inward, causing midline narrowing of the thoracic cavity. Although pectus excavatum may be visually prominent, in most cases the loss of volume is not significant and does not interfere with ventilation. Pectus excavatum is occasionally associated with upper or lower airway obstruction; however, when this condition is successfully treated or resolves spontaneously, the pectus deformity may lessen or disappear. Pectus excavatum may also be associated with segmental bronchomalacia, and in some patients, cardiac function may be adversely affected. In many children, the heart is shifted leftward, and in the rare patient, cardiac function may be adversely affected.

Surgical correction of pectus excavatum is not physiologically beneficial for the vast majority of patients; surgery is most often sought due to psychological and cosmetic concerns. However, for some patients with extreme deformity, operative interventions may be indicated for functional reasons.

Policy/Criteria

Surgical repair of pectus excavatum may be considered medically necessary when at least two of the following medical necessity criteria are met:

1. Documented progression of the deformity with associated symptoms.
2. Pulmonary function studies indicate components of restrictive airway disease.
3. Haller Computerized Tomography (CT) scan index greater than 3.25. This Haller CT index is the ratio derived from a chest CT scan by dividing the transverse diameter by the anterior-posterior diameter.
4. Cardiac evaluation (electrocardiogram [EKG], chest CT, and/or echocardiogram) demonstrates compression-caused mitral valve prolapse, abnormal rhythm, conduction abnormalities, or significant cardiac deformity.

REFERENCES

1. BlueCross BlueShield Association Medical Policy Reference Manual, Policy No. 10.01.09
2. BlueCross BlueShield Association Medical Policy Reference Manual, Policy No. 8.01.16
3. BlueCross BlueShield Association Medical Policy Reference Manual, Policy No. 7.01.40

CROSS REFERENCES

Orthognathic Surgery, Regence Medical Policy Manual, Surgery, Policy No. 137

Reconstructive Breast Surgery/Management of Breast Implants, Regence Medical Policy Manual, Surgery, Policy No. 40

Reduction Mammoplasty, Regence Medical Policy Manual, Surgery, Policy No. 60

Varicose Vein Treatment, Regence Medical Policy Manual, Surgery, Policy No. 104

Surgery Section Table of Contents