restorative/reconstructive/cosmetic surgery and treatment ... · cosmetic surgery performed...

Medical Policy Original Effective Date: 05-28-03

Revised Date: 03/27/2019 of 28

Restorative/Reconstructive/Cosmetic Surgery and Treatment MPM 18.5

Disclaimer Refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefit on all plans or the plan may have broader or more limited benefits than those listed in this Medical Policy. Prior Authorization is required for designated procedures. Log on to Pres Online to submit a request: https://ds.phs.org/preslogin/index.jsp

Definition Reconstructive Surgery: Reconstructive surgery is performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function but may also be done to approximate a normal or symmetric appearance.

1. Surgery to correct a physical functional disorder resulting from a disease or congenital anomaly;

2. Surgery to correct a physical functional disorder following an injury or illness

Cosmetic surgery performed for the purpose of enhancing one's appearance is not eligible for coverage. Additional cosmetic surgeries, done at the same time as reconstructive procedures, are not a covered benefit. Surgery will be considered cosmetic rather than reconstructive when there is no functional impairment present or the potential for functional improvement is not demonstrated. However, some congenital, acquired, traumatic or developmental anomalies may not result in functional impairment; and can be considered case-by-case bases for reconstructive surgery (unless non-covered by specific benefit plans).

Treatment of complications arising from cosmetic surgery will be considered on a case-by-case review as long as infection, hemorrhage or other serious documented medical complication occurs after beneficiary has been officially discharged from the facility.

Related Policies Other related Medical Policies, available through the following Web link: http://www.phs.org/phs/healthplans/providers/healthservices/Medical/index.htm MPM 27.0, Breast Surgical Procedures, includes:

• Breast Implant removal and/or replacement and capsulectomy;

• Breast reconstruction following mastectomy;

• Breast reduction mammoplasty;

https://ds.phs.org/preslogin/index.jsp

http://www.phs.org/phs/healthplans/providers/healthservices/Medical/index.htm





• Gynecomastia;

• Gynecomastia;

• Tattooing

• External Breast Prostheses MPM 2.82 and 2.81, Bariatric Surgery (Weight Loss Surgery) MPM 2.7, Blepharoplasty/Ptosis Surgery MPM 16.5, Panniculectomy and Abdominoplasty

MPM 16.9, Photodynamic Therapy for Skin and Cancer Conditions

MPM 16.10, Prophylactic Mastectomy and Oophorectomy MPM 22.1, Varicose Vein Procedures

Clinical Indications There must be supporting documentation that the physical

abnormality and/or physiological abnormality is interfering or causing a functional impairment that needs surgical correction or repair. Approved Indications:

• Procedures for congenital deformities for functional improvement.

• Specific congenital deformities of the ear, including microtia and anotia, associated with hearing impairment. Surgery is intended to correct the external ear deformity and improve the hearing impairment.

• Removal of Benign Skin Lesions: Lesions include: skin tags (e.g., seborrheic keratoses, epidermoid cysts, moles [nevi], acquired hyperkeratosis, molluscum contagiosum, milia, viral warts, benign neoplasms, hemangiomas, lipomas, and pyogenic granulomas, pre-auricular tags) which cause functional impairment, are suspicious for malignancy, or are located in areas where there has been repeated physical trauma and there is documentation that such trauma has occurred. (LCD L34938) Skin lesion that has become symptomatic or has

undergone a change in appearance or displays evidence of inflammation or infection (redness, pain, drainage or bleeding)

Lesion(s) obstructs an orifice. The lesion clinically restricts eye function. For example,

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34938&ver=52&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=SAD%7cEd&PolicyType=Both&s=39&KeyWord=actinic+keratosis&KeyWordLookUp=Doc&KeyWordSearchType=Or&kq=true&bc=IAAAACAAAAAA&




the lesion restricts eyelid function o causes misdirection of eyelashes or eyelid o restricts lacrimal puncta and interferes with tear

flow o touches the globe o interferes with vision

There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesion appearance or prior biopsy of a related or similar lesion suggesting malignancy

A prior histological exam or biopsy suggests or is indicative of atypia (e.g., atypical nevus) or malignancy.

The lesion is in an anatomical region subject to recurrent physical trauma and there is documentation that such trauma has occurred.

Removal of molluscum contagiosum Benign epidermal or pilar cyst with history of infection,

drainage, or rupture Wart removals/destruction when any of the following

clinical circumstances are present: o Periocular warts associated with chronic

recurrent conjunctivitis thought to be secondary to lesion virus shedding

o Warts showing evidence of spread from one body area to another

o Lesions are condyloma acuminate

• Note: For Senior Plan members only: Destruction of actinic keratosis, by any method, is covered without restrictions based on lesion or patient characteristics

• Destruction of actinic keratosis, by any method, is covered. Conventional methods (cryosurgery, topical drug therapy and curettage) do not require Prior Authorization. Chemical peels is covered for the treatment of actinic keratosis with prior authorization. (NCD 250.4)

• PHP follows MCG (ACG: A-0495). Scar revisions and keloid repairs when lesion causes limitation of motion or continuous pain, which is refractory to 3 months of analgesic treatment and present for 1 year or more. Signs or symptoms persist despite

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=129&ncdver=1&DocID=250.4&kq=true&bc=gAAAABAAAAAA&




conservative medical treatment. • Chest deformity associated with Poland Syndrome. All

requests must be reviewed by a Presbyterian medical director. The member may be eligible for surgical correction of the chest wall and/or breast deformity when one of the following criteria is met: Significant breast asymmetry, as evidenced by the

involved breast volume being less than 50% of the contralateral breast, OR

Chest wall deformity causing a functional deficit. • Reconstructive surgery on abnormal structures of the body,

caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease. Repair of a condition resulting from infections, disease, severe burns, accidental injury or conditions relating to deforming cancer surgery or non-cosmetic surgery. (LCD L34698 and L35090)

• Dermabrasion, segmental, face is covered for the treatment of rhinophyma.

• Rhinoplasty/reconstructive nasal surgery that is performed to improve nasal respiratory function due to airway obstruction or stricture, repair deficits caused by trauma, revise structural deformities produced by trauma or nasal cutaneous disease, or replace nasal tissue lost after tumor ablative surgery is covered. Rhinoplasty/reconstructive nasal surgery is covered for the following indications: Nasal fracture Benign or malignant neoplasms Nasal deformity secondary to a choanal atresia,

oronasal or oromaxillary fistula, cleft lip or cleft palate, congenital craniofacial deformity or to replace nasal tissue lost after tumor ablative surgery, which causes a functional impairment; or

Chronic Non-septal nasal obstruction when there is evidence on physical exam of either collapsed internal nasal valve at rest or collapse of lateral walls with inspiration; or

Secondary to trauma, disease, congenital defect or prior nasal surgery (i.e.septoplasty/turgbinectomy) with nasal

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34698&ver=25&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=SAD%7cEd&PolicyType=Both&s=39&KeyWord=actinic+keratosis&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=IAAAACAAAAAA&

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35090&ver=36&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=SAD%7cEd&PolicyType=Both&s=39&KeyWord=septoplasty&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=IAAAACAAAAAA&




airway obstruction unresponsive to a recent trial of conservative medical management lasting at least six weeks.

As part of a larger surgical procedure for repair of nasal fracture (e.g., osteotomy, reduction of nasal bones) causing severe airway obstruction that will not respond to septoplasty and turbinectomy alone. (Examples of nasal obstruction affecting quality of life include sleep apnea unresponsive to CPAP, or chronic rhinosinusitis). Fracture must be documented and have occurred within the past one year. Nasal obstruction should be 50% or greater.

The following documentation must accompany requests for rhinoplasty:

o History of deformity or trauma o Physical examination documenting nasal

obstruction o Preoperative photographs showing the base of

the nose, anterior posterior, right/left lateral views

• Septoplasty is considered 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 six 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 trans nasal 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.

• Punch graft hair transplant may be considered reconstructive when it is performed for eyebrow(s) replacement following a burn injury or tumor removal.

• Tattooing to correct color defects of the skin may be considered reconstructive when performed in connection with a payable post-mastectomy reconstruction, or for reconstruction following trauma or removal of cancer from an eyelid, eyebrow or lip(s).

• Dermal injections for facial LDS using dermal fillers approved by the FDA for this purpose, and then only in HIV-infected Medicare beneficiaries who manifest depression secondary to the physical stigma of HIV treatment will be covered.

• Dermal Injection for the Treatment of Facial Lipodystrophy Syndrome. See Pub 100-03, Medicare National Coverage Determinations Chapter 1, Coverage Determinations Part 4, Section 250.5, See Pub. 100-04, Claims Processing Manual, Chapter 32, Section 260, Dermal Injection for the Treatment of Facial Lipodystrophy Syndrome.

• Dermal Injections for the treatment of Facial Lipodystrophy Syndrome, National Coverage Determination NCD (250.5)

• The following procedures will be considered on a case-by case individual basis.

Rhytidectomy is considered medically necessary to correct a functional impairment as a result of a disease state ie; facial paralysis. Often this procedure is performed in conjunction with other procedures to correct the impairment.

Excision, excessive skin and subcutaneous tissue (including lipectomy); abdomen (abdominoplasty) will only be considered reasonable and medically necessary when these procedures are performed due to another surgery being done at the same time and would effect the healing of the surgical incision.

o This procedure may also be considered to be medically necessary for the patient that has had a significant weight-loss following the

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf



https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c32.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c32.pdf

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=338&ncdver=1&DocID=250.5&bc=gAAAABAAAAAA&




treatment of morbid obesity and there are medical complications such as candidiasis, intertrigo or tissue necrosis that is unresponsive to oral or topical medication.

Complications of Cosmetic Surgery

Cosmetic surgery performed primarily to improve appearance and self-esteem is not a covered benefit. Complications due to cosmetic surgery are only covered for life-threatening situations requiring emergency hospitalization or treatment. For cosmetic surgery done as an inpatient, life-threatening complications are only covered after discharge from the hospital stay during which the non-covered cosmetic surgery was performed. Only treatment of the complication is covered, not revision of the original surgery.

Dental Services Dental services whether or not the disorder is related to a medical condition or occurring as a result of treatment for a medical condition, are not a covered benefit. Reconstructive dental services are covered only for those circumstances stated in the member’s specific benefit plan.- NMAC non-covered service (8.301.3.13)

Exclusions and Limitations

Non-covered procedures not limited to the following: • PHP uses CMS LCD (L35090 and L34698) for the following

examples of conditions or procedures that are excluded from coverage:

• Cosmetic surgery performed to treat psychiatric or emotional problems is not covered

• 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.

• Rhinoplasty is not covered 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.

• Any surgical procedure solely directed at improving a normal appearance.

• Breast augmentation or procedures to correct asymmetry, except as described in Poland Syndrome on page 4.

• Deformities related to body piercing, the wearing of earrings,

http://www.hsd.state.nm.us/uploads/FileLinks/db231204433241998f49d260c6129473/8.301.3_Eff_3.1.2006.pdf

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35090&ver=36&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=SAD%7cEd&PolicyType=Both&s=39&KeyWord=septoplasty&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=IAAAACAAAAAA&





ear piercing (including torn ear lobe) or keloid scarring of the structures of the ear, whether symptomatic or not.

• Treatment of wrinkles, by any modality.

• Congenital deformities not causing functional impairment including potential psychological situations – such as protruding ears, low set ears, large ears, nasal humps or asymmetry, gynecomastia.

• Face-lift, except when injuries due to burns, trauma and disease may warrant a limited face-lift within 2 years of the burn or injury (excluding burns induced by cosmetic procedures such as cosmetic peels).

• Genioplasty

• Rhinophyma

• Tattoo removal by any method including laser or salabrasion.

• Photodynamic therapy for acne vulgaris. Includes laser, Intense Pulsed Light (IPL), Infrared. ClearLight TM or “Blue Light” treatment

• Dermal fillers, such as collagen injections for the treatment of acne scars or any other cosmetic abnormality.

• Chemical peels or dermabrasion for treating acne scars or any other dermatological lesion. (Exception: See “destruction of actinic keratosis” on page 3).

• Removal, injection or laser treatment of spider angiomata (spider veins – small asymptomatic varicose veins <3 mm in diameter)

• Treatment of asymptomatic varicose veins and spider telangiectasia.

• Hair transplants (except for when it is performed for eyebrow(s) replacement following a burn injury or tumor removal)

• Hair removal either by electrolysis or laser (Laser hair removal may be considered reconstructive and medically necessary when used to remove hair from transplanted flaps and skin rearrangements used to repair deficits caused by trauma or tumor extirpation. The medical record must support the indications for this service and the claim should be submitted with CPT code 17999.)

• Additional surgery or treatment required to care for or correct a complication of a non-covered cosmetic procedure is not a




covered benefit except as described on page 7, under the heading “Complications of Cosmetic Surgery.

• Limited surgical procedures are covered for individuals diagnosed with gender dysphoria, refer to MPM 7.3

• NMAC – Cosmetic Services and Surgeries:MAD does not cover cosmetic items or services that are prescribed or used for aesthetic purposes. This includes items for aging skin, for hair loss. MAD does not cover cosmetic surgeries performed for aesthetic purposes. “Cosmetic surgery” is defined as procedures performed to improve the appearance of physical features that may or may not improve the functional ability of the area of concern. MAD covers only surgeries that meet specific criteria and are approved as medically necessary reconstructive surgeries

Coding The coding listed in this Medical Policy is for reference only. Covered and non-covered procedures are included in this list. Note: this is not an all inclusive list.

Removal of Benign Skin Lesions (L34938)

CODE For removal of benign skin lesions. CPT codes covered if selection criteria are met

11200 Removal of skin tags <w/15 11201 Remove skin tags add-on 11310 Shave skin lesion 0.5 cm/< 11311 Shave skin lesion 0.6-1.0 cm 11312 Shave skin lesion 1.1-2.0 cm 11313 Shave skin lesion >2.0 cm 11440 Exc face-mm b9+marg 0.5 cm/<

11441 Exc face-mm b9+marg 0.6-1 cm

11442 Exc face-mm b9+marg 1.1-2 cm 11443 Exc face-mm b9+marg 2.1-3 cm 11444 Exc face-mm b9+marg 3.1-4 cm 11446 Exc face-mm b9+marg >4 cm 17106 Destruction of skin lesions

https://www.phs.org/providers/Documents/Gender-Dysphoria-Gender-Idenitity-Disorder-Treatment-MPM-7-3.pdf





17107 Destruction of skin lesions 17108 Destruction of skin lesions 17340 Cryotherapy of skin 11300 Shave skin lesion 0.5 cm/< 11301 Shave skin lesion 0.6-1.0 cm 11302 Shave skin lesion 1.1-2.0 cm 11303 Shave skin lesion >2.0 cm 11400 Exc tr-ext b9+marg 0.5 cm< 11401 Exc tr-ext b9+marg 0.6-1 cm 11402 Exc tr-ext b9+marg 1.1-2 cm 11403 Exc tr-ext b9+marg 2.1-3cm 11404 Exc tr-ext b9+marg 3.1-4 cm 11406 Exc tr-ext b9+marg >4.0 cm 11305 Shave skin lesion 0.5 cm/< 11306 Shave skin lesion 0.6-1.0 cm 11307 Shave skin lesion 1.1-2.0 cm 11308 Shave skin lesion >2.0 cm 11420 Exc h-f-nk-sp b9+marg 0.5/< 11421 Exc h-f-nk-sp b9+marg 0.6-1 11422 Exc h-f-nk-sp b9+marg 1.1-2 11423 Exc h-f-nk-sp b9+marg 2.1-3 11424 Exc h-f-nk-sp b9+marg 3.1-4 11426 Exc h-f-nk-sp b9+marg >4 cm 17000 Destruct premalg lesion 17003 Destruct premalg les 2-14 17004 Destroy premal lesions 15/> 17110 Destruct b9 lesion 1-14 17111 Destruct lesion 15 or more





46900 Destruction anal lesion(s) 46916 Cryosurgery anal lesion(s) 54050 Destruction penis lesion(s) 54055 Destruction penis lesion(s) 54056 Cryosurgery penis lesion(s) 54057 Laser surg penis lesion(s) 54060 Excision of penis lesion(s) 54065 Destruction penis lesion(s) 56501 Destroy vulva lesions sim 56515 Destroy vulva lesion/s compl

For ICD-10 Codes (diagnosis) for above CPT codes see CMS LCD (L34938). Note: The following CPT codes: 11200, 11200, 11201, 17106, 17107, 17108 and 17340 will not have diagnosis limitations applied at this time

Cosmetic and Reconstructive Surgery

CODE Cosmetic and Reconstructive Surgery per (L34698 and L35090). CPT codes covered if selection criteria are met

11920 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less

11921 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm

11922

Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (list separately in addition to code for primary procedure)

15780 Dermabrasion; total face (eg, for acne scarring, fine

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34938&ver=52&Date=03%2f01%2f2019&DocID=L34938&bc=iAAAABAAAAAA&





wrinkling, rhytids, general keratosis) 15781 Dermabrasion; segmental, face 15782 Dermabrasion; regional, other than face 15783 Dermabrasion; superficial, any site, (eg, tattoo

removal) 15775 Punch graft for hair transplant; 1 to 15 punch grafts

15776 Punch graft for hair transplant; more than 15 punch grafts

15781 Dermabrasion; segmental, face 15788 Chemical peel, facial; epidermal 15789 Chemical peel, facial; dermal 15792 Chemical peel, nonfacial; epidermal 15793 Chemical peel, nonfacial; dermal 15828 Rhytidectomy; cheek, chin, and neck

15829 Rhytidectomy; superficial musculoaponeurotic system (smas) flap

15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraubilical panniculectomy

17999 Unlisted procedure, skin, mucous membrane and subcutaneous tissue, (Laser Hair removal)

30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip

30410

Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip; complete, external parts including bony pryramid, lateral and alar cartilages, and/or elevation of nasal tip

30420 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip; including major septal repair

30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work)

30435 Rhinoplasty, secondary; minor revision (small amount of nasal tip work); intermediate revision (bony work





with osteotomies)

30450 Rhinoplasty, secondary; minor revision (small amount of nasal tip work); major revision (nasal tip work and osteotomies)

30460 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only

30462 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies

G0429 Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (lds) (e.g., as a result of highly active antiretroviral therapy)

Q2026 Injection, radiesse, 0.1 ML Q2028 Injection, sculptra, 0.5 MG

Scar Revisions

CPT codes Scar Revisions: CPT codes covered if selection criteria are met

15002

Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children;

15003

Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children

15004

Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body




CPT codes Scar Revisions: CPT codes covered if selection criteria are met area of infants and children

+15005

Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure)

23921 Disarticulation of shoulder; secondary closure or scar revision

24149 Radical resection of capsule, soft tissue and heterotopic bone, elbow, with contracture release (separate procedure)

24925 Amputation, arm through humerus; secondary closure or scar revision

25907 Amputation, forearm, through radius and ulna; secondary closure or scar revision

25922 Disarticulation through wrist; secondary closure or scar revision

25929 Transmetacarpal amputation; secondary closure or scar revision

26121 Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting

26123

Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting;

+26125 each additional digit (list separately in addition to code for primary procedure)

26508 Release of thenar muscle(s) (eg, thumb contracture)

27594 Amputation thigh, through femur, any level; secondary closure or scar revision

27884 Amputation, leg, through tibia and fibula; secondary closure or scar revision

31830 Revision of tracheostomy scar




CPT codes Scar Revisions: CPT codes covered if selection criteria are met

67343 Release of extensive scar tissue without detaching extraocular muscle (separate procedure)

Poland’s Syndrome

CPT Poland’s Syndrome: CPT codes covered if selection criteria are met

11960 Insertion of tissue expander(s) for other than breast, including subsequent expansion

11970 Replacement of tissue expander with permanent prosthesis

11971 Removal of tissue expander(s) without insertion of prosthesis

19340 Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction

19342 Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction

19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion

19361 Breast reconstruction with latissimus dorsi flap, without prosthetic implant

19364 Breast reconstruction with free flap 19366 Breast reconstruction with other technique

19367 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site

19368 with microvascular anastomosis (supercharging)

19369 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site

20900 Bone graft, any donor area; minor or small (e.g., dowel or button)

20902 major or large ICD-10 Code ICD-10 codes for Poland’s Syndrome

Q79.8 Other congenital malformations of musculoskeletal system [Poland's syndrome]




Congenital Defect (Cleft lip/Palate and nasal deformity)

CPT CPT for: Repair of cleft lip/Palate and nasal deformity, this list is not inclusive

21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)

21209 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant); reduction

40525 Excision of lip; transverse wedge excision with primary closure; full thickness, reconstruction with local flap (eg, Estlander or fan)

40527 Excision of lip; transverse wedge excision with primary closure; full thickness, reconstruction with cross lip flap (Abbe-Estlander)

40700 Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral

40701 Plastic repair of cleft lip/nasal deformity; primary bilateral, 1-stage procedure

40702 Pleastic repair of cleft lip/nasal deformity; primary bilateral , 1 or 2 stages

40720 Plastic repair of cleft lip/nasal deformity; secondary, by recreation of defect and reclosure

40761 Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap (Abbe-Eslander type), including sectioning and inserting pedicle

30460 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only

30462 tip, septum, osteotomies 42200 Palatoplasty for Cleft Palate, soft and/or hard palate only

42205 Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only

42210 with bone graft to alveolar ridge (includes obtaining graft)

42215 Palatoplasty for cleft palate; major revision 42220 secondary lengthening procedure 42225 attachment pharyngeal flap

ICD-10 Use appropriate ICD-10 code range for Cleft defects Q36.0 – Q36.9 Cleft lip Q37.0 – Q37.9 Cleft plate with cleft lip

Congenital facial deformity Repair




CPT codes CPT for Repair, revision, and/or Reconstruction facial deformity

21120 Genioplasty; augmentation (autograft, allograft, prosthetic material)

21121 Genioplasty; sliding osteotomy, single piece

21122 Genioplasty; sliding osteotomies, two or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin)

21123 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)

21125 Augmentation, mandibular body or angle; prosthetic material

21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft)

21137 Reduction forehead; contouring only

21138 Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft)

21139 Reduction forehead; contouring and setback of anterior frontal sinus wall

21141 Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft

21142 Reconstruction midface, LeFort I; two pieces, segment movement in any direction, without bone graft

21143 Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, without bone graft

21145 Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts)

21146

Reconstruction midface, LeFort I; two pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft)

21147

Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies)

21150 Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome)

21151 Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts)




CPT codes CPT for Repair, revision, and/or Reconstruction facial deformity

21154 Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I

21155 Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I

21159

Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I

21160

Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I

21172 – 21196 Repair, revision, and/or reconstruction bones of face

21206 Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)

21210 Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)

21247 Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial acrosomia)

D7946 – D7949 Lefort Procedures I, II, or III

ICD-10 Congenital Facial Anomalies applicable to CPT codes above

Q67.0 – Q67.4 Congenital deformities of skull, face and jaw

Q75.0 – Q75.9 Congenital malformation of skull and face bones [includes hemifacial microstomia]

Q87.0 Congenital malformation syndromes predominately affecting facial appearance

Microtia and Atresia Repair

CPT Ear repair (microtia) to improve hearing and Atresia

14061 Adjacent issue transfer or rearrangement, ears,; defct 10.1 sq cm to 30.0 sq cm

15120 Split-thickness autograft, ears; first 100 sq cm or




CPT Ear repair (microtia) to improve hearing and Atresia less, or 1% of body area of infants and children

69310 Reconstruction of external auditory canal

69320 Reconstruction external auditory canal for congenital atreasia, single stage

69399 Unlisted procedure, external ear (requires additional report/information to be submitted

21230 Graft; rib cartilage, autogenous, to ear 21235 Graft, ear cartilage, autogenous, to nose or ear D5914 Auricular prosthesis ICD-10 Microtia and atresia

Q16.0 Congenital absence of (ear) auricle` causing impairment of hearing

Q16.1 Congenital absence, atresia and stricture of auditory canal

TMJ repair

CPT Arthroplasty for Temporomandibular Joint

21240 Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)

21242 Arthroplasty, temporomandibular joint, with allograft

21243 Arthroplasty, temporomandibular joint, with prosthetic joint replacement

ICD-10 Use Appropriate ICD-10 applicable to TMJ condition

M26.60 – M26.69 Temporomandibular joint disorders

CPT Codes Other Surgery Integumentary repair due to injury/trauma. (Use ICD-10 applicable to these CPTs)

13100 - 13160 Reconstructive procedures, Complex. (see CPT code book for full description

14000- 14350 Adjacent Tissue Transfer or Rearrangement




CPT Codes Other Surgery Integumentary repair due to injury/trauma. (Use ICD-10 applicable to these CPTs)

15002 - 15278 Skin Replacement Surgery 15570 -15738 Flaps (Skin and/or deep tissues 15740 - 15760 Other Flaps and Grafts

HCPCS Level II D5916 Ocular prosthesis

D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla, autogenous or nonautogenous, by report

D7995 Synthetic Graft – mandible or facial bones, by report

L8040 – L8049 Nasal, midfacial, orbital, upper facial, hemo-facial, auricular, partial fascial, nasal septal, and maxillofacial prostheses

L8610 Ocular implant Q3031 Collagen skin test

V2623 – V2629 Prosthetic eye

Diagnosis Listings

ICD-10 CODE Diagnosis for Dermabrasion: CPT codes (15780, 15781, 15782 and 15783) covered if selection criteria are met

L71.0 Perioral dermatitis L71.1 Rhinophyma L71.8 Other rosacea L71.9 Rosacea, unspecified

ICD-10 codes

Diagnosis for Punch graft hair transplant: CPT codes (15775 and 15776) covered if selection criteria are met. *7th character can be letter A, D, or S

C44.300 Unspecified malignant neoplasm of skin of unspecified part of face

C44.309 Unspecified malignant neoplasm of skin of other parts of face

C44.310 Basal cell carcinoma of skin of unspecified parts of face




ICD-10 codes


C44.319 Basal cell carcinoma of skin of other parts of face

C44.320 Squamous cell carcinoma of skin of unspecified parts of face

C44.329 Squamous cell carcinoma of skin of other parts of face

C44.390 Other specified malignant neoplasm of skin of unspecified parts of face

C44.399 Other specified malignant neoplasm of skin of other parts of face

D04.30 Carcinoma in situ of skin of unspecified part of face D04.39 Carcinoma in situ of skin of other parts of face D04.8 Carcinoma in situ of skin of other sites

D22.30 Melanocytic nevi of unspecified part of face D22.39 Melanocytic nevi of other parts of face

D23.30 Other benign neoplasm of skin of unspecified part of face

D23.39 Other benign neoplasm of skin of other parts of face D48.5 Neoplasm of uncertain behavior of skin

S09.10XA Unspecified injury of muscle and tendon of head, initial encounter

S09.11XA Strain of muscle and tendon of head, initial encounter

S09.19XA Other specified injury of muscle and tendon of head, initial encounter

S09.8XXA Other specified injuries of head, initial encounter

T20.26XA Burn of second degree of forehead and cheek, initial encounter

T20.36XA Burn of third degree of forehead and cheek, initial encounter

T20.66XA Corrosion of second degree of forehead and cheek, initial encounter

T20.76XA Corrosion of third degree of forehead and cheek, initial encounter

T20.06XA Burn of unspecified degree of forehead and cheek,




ICD-10 codes


initial encounter

T20.06XD Burn of unspecified degree of forehead and cheek, subsequent encounter

T20.06XS Burn of unspecified degree of forehead and cheek, sequela

T20.16XA Burn of first degree of forehead and cheek, initial encounter

T20.16XD Burn of first degree of forehead and cheek, subsequent encounter

T20.16XS Burn of first degree of forehead and cheek, sequela

T20.26XA Burn of second degree of forehead and cheek, initial encounter

T20.26XD Burn of second degree of forehead and cheek, subsequent encounter

T20.26XS Burn of second degree of forehead and cheek, sequela

T20.36XA Burn of third degree of forehead and cheek, initial encounter

T20.36XD Burn of third degree of forehead and cheek, subsequent encounter

T20.36XS Burn of third degree of forehead and cheek, sequela

Z48.89* Encounter for other specified surgical aftercare (Use Z48.89 for punch graft procedures performed for eyebrow replacement due to removal of tumor)

ICD-10 CODE Diagnosis for Rhinoplasty (CPT 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462) 7TH character letters can be A, B, D, G, K, Or S

C30.0 Malignant neoplasm of nasal cavity C41.0 Malignant neoplasm of bones of skull and face

C43.31 Malignant melanoma of nose C43.39 Malignant melanoma of other parts of face





C44.301 Unspecified malignant neoplasm of skin of nose

C44.309 Unspecified malignant neoplasm of skin of other parts of face

C44.311 Basal cell carcinoma of skin of nose C44.319 Basal cell carcinoma of skin of other parts of face C44.321 Squamous cell carcinoma of skin of nose

C44.329 Squamous cell carcinoma of skin of other parts of face

C44.391 Other specified malignant neoplasm of skin of nose

C44.399 Other specified malignant neoplasm of skin of other parts of face

C76.0 Malignant neoplasm of head, face and neck D03.39 Melanoma in situ of other parts of face D04.30 Carcinoma in situ of skin of other parts of face

D14.0 Benign neoplasm of middle ear, nasal cavity and accessory sinuses

D16.4 Benign neoplasm of bones of skull and face D22.39 Melanocytic nevi of other parts of face D22.30 Melanocytic nevi of unspecified part of face

D23.30 Other benign neoplasm of skin of unspecified part of face

D23.39 Other benign neoplasm of skin of other parts of face J32.0 Chronic maxillary sinusitis J32.1 Chronic frontal sinusitis J32.2 Chronic ethmoidal sinusitis J32.3 Chronic sphenoidal sinusitis J32.4 Chronic pansinusitis J34.0 Abscess, furuncle and carbuncle of nose J34.1 Cyst and mucocele of nose and nasal sinus J34.2 Deviated nasal septum J34.89 Other specified disorders of nose and nasal sinuses





Q30.0 Choanal atresia Q30.8 Other congenital malformations of nose Q35.1 Cleft hard palate Q35.3 Cleft soft palate Q35.5 Cleft hard palate with cleft soft palate Q35.7 Cleft uvula Q36.0 Cleft lip, bilateral Q36.1 Cleft lip, median Q36.9 Cleft lip, unilateral Q37.0 Cleft hard palate with bilateral cleft lip Q37.1 Cleft hard palate with unilateral cleft lip Q37.2 Cleft soft palate with bilateral cleft lip Q37.3 Cleft soft palate with unilateral cleft lip Q37.4 Cleft hard and soft palate with bilateral cleft lip Q37.5 Cleft hard and soft palate with unilateral cleft lip Q37.8 Unspecified cleft palate with bilateral cleft lip Q37.9 Unspecified cleft palate with unilateral cleft lip Q67.0 Congenital facial asymmetry Q67.1 Congenital compression facies Q67.2 Dolichocephaly Q67.3 Plagiocephaly Q67.4 Other congenital deformities of skull, face and jaw R04.0 Epistaxis

R09.81 Nasal congestion

S02.2XXA Fracture of nasal bones, initial encounter for closed fracture

S02.2XXB Fracture of nasal bones, initial encounter for open fracture

S02.2XXD Fracture of nasal bones, subsequent encounter for fracture with routine healing





S02.2XXG Fracture of nasal bones, subsequent encounter for fracture with delayed healing

S02.2XXK Fracture of nasal bones, subsequent encounter for fracture with nonunion

S02.2XXS Fracture of nasal bones, sequela

ICD-10 code Diagnosis for Tattooing (CPT: 11920, 11921, 11922)

Z42.8 Encounter for other plastic and reconstructive surgery following medical procedure or healed injury

L81.8 Other specified disorders of pigmentation L81.9 Disorder of pigmentation, unspecified

ICD-10 code Diagnosis for Chemical Peel (CPT: 15788 – 15793)

L57.0 Actinic Keratosis

ICD-10 code Diagnosis for dermabrasion (CPT:15781) L71.0 Perioral Dermatitis L71.1 Rhinophyma L71.8 Other rosacea

ICD-10 code Diagnosis for Dermal Filler injection(s) (HCPCS:

G0429) B20 Human immunodeficiency virus (HIV) disease

E88.1 Lipodystrophy, not elsewhere classified

ICD-10 code Diagnosis for Injection Radiesse, 0.1ml (HCPCS: Q2026)

B20 Human immunodeficiency virus (HIV) disease E88.1 Lipodystrophy, not elsewhere classified

ICD-10 code Diagnosis for Injection Sculptra, 0.1ml (HCPCS: Q2028)

B20 Human immunodeficiency virus (HIV) disease E88.1 Lipodystrophy, not elsewhere classified

Reviewed by:: 1. William Chapman, MD, Dermatology Consultants of Albuquerque,

PC. February 2003, June 2005




2. Luis Cuadros, MD, FACS, Plastic Surgery. February 2003, November/December 2006, January 2008, May 2009

3. Neil Chen, MD, Plastic Surgery. April 2004, July 2005 4. John M. Finley, MD, PMG Plastic Surgery, Albuquerque, NM. May

2009.

References: 1. Social Security Act, Section 1862. [42 U.S.C. 1395y]. Exclusions from Coverage and Medicare as Secondary Payer; Effective December 10, 2016. Accessed 01/08/2019. No change in law, except insertion of new subparagraph (D).

2. CMS, LCD (L35090) Cosmetic and Reconstructive Surgery, Revision 04/14/2017, Revision #4. Accessed 03/19/2019.

3. CMS, LCD (L34698), Cosmetic and Reconstructive Surgery, Revision date 12/01/2018, R#10. [Cited 03/19/2019]

4. CMS, MLN, Items and Services Not Covered Under Medicare, ICN 906765, August 2018. Accessed 01/08/2019

5. CMS, LCD (L34938), Removal of Benign Skin Lesions, Revised 10/01/2018 with revision number R9. Accessed 03/19/2019

6. American Society of Plastic Surgeons, Health Policy, ASPS Recommended Insurance Coverage Criteria, Copyright© 2019. Accessed 01/08/2019

7. MCG Health General Recovery Care Guidelines®, 23rd Edition. Head and Neck Surgery or Procedure General Recovery Guidelines. GRG: SG-HNS (ISC GRG). Last Update 02/11/2019. [Cited 03/19/2019]

8. MCG General Recovery Care, 23rd Edition. Wound and Skin Management General Recovery Guidelines. GRG: PG-WS (ISC GRG). Last Update 02-11-2019. Accessed 03/019/2019.

9. MCG Ambulatory Care 23rd Edition, Scar Revision. Ambulatory Care Guideline (A-0495 (AC). Last Update 02-11-19. Accessed 03/19/2019.

10. MCG Ambulatory Care, 23st Edition, Rhinoplasty. Ambulatory Care Guideline A-0184 (AC). Last Update 02-11-19. Accessed 03-19-2019.

11. Centers for Medicare and Medicaid Services. NCD for Treatment of Actinic Keratosis (250.4). Effective date: 11-26-01. No other changes. [Cited 03/19/19]

12. New Mexico Adminstrative Code (NMAC) The Office of Superintendent of Insurance (OSI) can be accessed at

https://www.ssa.gov/OP_Home/ssact/title18/1862.htm

https://www.ssa.gov/OP_Home/ssact/title18/1862.htm

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35090&ver=36&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=SAD%7cEd&PolicyType=Both&s=39&KeyWord=cosmetic+surgery&KeyWordLookUp=Doc&KeyWordSearchType=And&kq=true&bc=IAAAACAAAAAA&


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Items-and-Services-Not-Covered-Under-Medicare-Booklet-ICN906765.pdf

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34938&ver=52&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=SAD%7cEd&PolicyType=Both&s=39&KeyWord=cosmetic+surgery&KeyWordLookUp=Doc&KeyWordSearchType=And&kq=true&bc=IAAAACAAAAAA&

https://www.plasticsurgery.org/for-medical-professionals/health-policy/recommended-insurance-coverage-criteria

https://www.plasticsurgery.org/for-medical-professionals/health-policy/recommended-insurance-coverage-criteria

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=129&ncdver=1&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=SAD%7cEd&PolicyType=Both&s=39&KeyWord=actinic+keratosis&KeyWordLookUp=Doc&KeyWordSearchType=Or&kq=true&bc=IAAAACAAAAAA&




• NMAC Title 13.10.13.9.C (4), SUPPLEMENTAL HEALTH CARE SERVICES, cosmetic surgery. Last update 9/1/2009. Accessed 03/21/2019

• NMAC Title 8.310.2.13.D GENERAL NONCOVERED SERVICES Cosmetic services and surgeries, Effective 1/1/14. Accessed 03/21/2019

• NMAC Title 13.10.21.8.G(5) Other mandated benefits; Effective 09-01-2009. Assessed 03/21/2019

13. Wilhemi, B.J., MD. Breast, Poland Syndrome. eMedicine, last updated 07-03, 2018. Accessed 06-25-10 at: http://www.emedicine.com/plastic/TOPIC132.HTM. Accessed 03/20/2019.

14. Aetna, Pectus Excavatum and Poland’s Syndrome: Surgical Correction. Clinical Policy Bulletin No. 0272. Last Review: 06/08/2018, Next Review: 03/14/2019

Approval Signatures: Clinical Quality Committee: Norman White MD

Medical Director: David Yu MD

Approval Date: March 27, 2019

Publication History: May 2003 Effective Date May 2004 Review Date 11/2006 Review Date January 2008 Review Date: June 2004 Review Date July 2005 Review Date 11/2005 Review Date Jan 2007 Review Date Feb 2008 Review Date Jan 2007 Review Date 06-24-09: Annual Review and Revision. 01-27-10: Revision: Dental Services section added 06-23-10: Annual Review 02-22-12: Annual Review and revision 01-29-14: Annual Review 03-25-15: Annual Review

http://164.64.110.134/nmac/nmac-titles

http://164.64.110.134/parts/title13/13.010.0013.html





http://www.emedicine.com/plastic/TOPIC132.HTM.%20Accessed%2003/20/2019

http://www.emedicine.com/plastic/TOPIC132.HTM.%20Accessed%2003/20/2019

http://www.aetna.com/cpb/medical/data/200_299/0272.html




05-25-16: Annual review. Removed ICD 9 codes. 03-27-19: Annual review. Update CPT and ICD-10 codes

This Medical Policy is intended to represent clinical guidelines describing medical appropriateness and is developed to assist Presbyterian Health Plan and Presbyterian Insurance Company, Inc. (Presbyterian) Health Services staff and Presbyterian medical directors in determination of coverage. The Medical Policy is not a treatment guide and should not be used as such. For those instances where a member does not meet the criteria described in these guidelines, additional information supporting medical necessity is welcome and may be utilized by the medical director in reviewing the case. Please note that all Presbyterian Medical Policies are available on the Internet at: http://www.phs.org/phs/healthplans/providers/healthservices/Medical/index.htm
