Cosmetic surgery is performed to reshape normal structures of the body in order to improve the individual's appearance.
Reconstructive surgery is performed to improve or restore functional impairment or to alleviate pain and physical discomfort resulting from a condition, disease, illness, or congenital birth defect.
Abdominoplasty, Panniculectomy (Tummy Tuck) may be considered medically necessary when ALL of the following criteria are met:
NOTE: The individual must be 18 months postoperative following bariatric surgery.
Abdominoplasty and/or panniculectomy are considered cosmetic and, therefore, non-covered for all other indications.
15830 |
15847 |
17999 |
|
|
|
|
Blepharoplasty, Brow lift, AND Blepharoptosis may be considered medically necessary for ANY of the following conditions:
AND
When ALL of the following criteria are met:
Blepharoplasty, Lower Lid may be considered medically necessary for reconstructive repair where there is functional visual impairment due to any ONE of the following conditions:
AND
NOTE: When the physician has determined that the individual requires a bilateral blepharoplasty, bilateral blepharoptosis repair or a bilateral brow ptosis repair, it is expected that the procedures will be performed on the same date of service. Bilateral procedures performed on different dates of service require the submission of medical record documentation to support the medical necessity of performing these procedures on different dates of service.
Blepharoplasty, brow lift, and blepharoptosis are considered cosmetic and, therefore, non-covered when the above medical necessity is not met.
15820 |
15821 |
15822 |
15823 |
67900 |
67901 |
67902 |
67903 |
67904 |
67906 |
67908 |
67909 |
67911 |
|
Canthopexy may be considered medically necessary when performed for any ONE of the following conditions:
Canthopexy is considered cosmetic and, therefore, non-covered when the above medical necessity is not met.
21280 |
21282 |
|
|
|
|
|
Cryotherapy (e.g. Cryosurgery) may be considered medically necessary when performed for diagnoses other than active acne.
Cryotherapy performed for the treatment of active acne is considered cosmetic and, therefore, non-covered.
17000 |
17003 |
17004 |
17340 |
67825 |
|
|
Dermabrasion may be considered medically necessary when correcting defects resulting from an accident or when functional impairment exists.
Dermabrasion is considered cosmetic and, therefore, non-covered for any other indication.
15780 |
15781 |
15782 |
15783 |
15786 |
15787 |
|
Earlobe Surgery may be considered medically necessary when repairing an earlobe defect if the defect is a through and through laceration resulting in a bilobe earlobe.
Repair of a defect that does not result in a bilobe earlobe (e.g., a large hole resulting from wearing heavy jewelry) is considered cosmetic and, therefore, non-covered.
12011 |
12051 |
13151 |
|
|
|
|
Facial Surgery, Corrective will be considered cosmetic rather than reconstructive when there is not any functional impairment present.
An indication or a diagnosis of pain may qualify as functional impairment.
Psychiatric indications do not warrant payment for cosmetic surgery when no functional impairment is present. However, severe psychological impairment, appropriately documented, can be classified as significant functional impairment on an individual consideration basis.
In cases involving psychiatric disorder or involutional changes due to aging, the claim should be accompanied by a report from a psychiatrist who indicates a definite psychiatric condition relevant to the condition to be corrected by the surgery and that the proposed correction is likely to be of significant help in treating the psychiatric problem. These services require medical review prior to payment.
Hair Removal (Permanent) by any method (e.g., by electrolysis) may be considered medically necessary when BOTH of the following criteria are met:
NOTE: Electrolysis and laser hair removal performed for hirsutism is classified as cosmetic and, therefore, not covered.
Hair removal is considered cosmetic and, therefore, non-covered for any other indication
17380 |
17999 |
|
|
|
|
|
Hair Transplant may be considered medically necessary when performed as a result of injury or burn.
Hair transplant is considered cosmetic and, therefore, non-covered for any other indication.
15220 |
15221 |
15775 |
15776 |
|
|
|
Mammoplasty, Augmentation may be considered medically necessary when ANY of the following criteria are met:
Augmentation mammoplasty is considered cosmetic and, therefore, non-covered when the above medical necessity is not met.
NOTE: Surgery on an unaffected breast in order to provide symmetry with a breast on which a mastectomy and reconstructive procedure have been performed may be considered medically necessary.
Charges for implantable breast prosthesis are eligible when the implant is provided in conjunction with a reconstructive augmentation mammoplasty. However, if the augmentation mammoplasty is classified as cosmetic, charges for the implant will be denied as cosmetic.
L8600 |
19325 |
19499 |
|
|
|
|
Mammoplasty, Reduction/Breast Reduction may be considered medically necessary when ALL of the following criteria are met:
The appropriate amounts (in grams) of breast tissue must be anticipated for removal from AT LEAST one (1) breast, which is based on the individual's total BSA in meters squared.
Reduction mammoplasty performed solely to remove fat and/or skin, but not the minimum specimen weight of breast tissue outlined above, is considered not medically necessary.
If preferred, there are several websites with calculators to assist in calculating body surface area, an example is http://www.globalrph.com/bsa2.htm.
Reduction mammoplasty/breast reduction are considered cosmetic and, therefore, non-covered when the above medical necessity is not met.
19318 |
19499 |
|
|
|
|
|
Mastectomy For Gynecomastia
Mastectomy for gynecomastia is considered reconstructive when ALL of the following criteria are met:
If the above criteria are not met, services may be considered medically necessary when it is documented that the tissue is primarily breast tissue, by pathology report, and not just adipose (fatty) tissue.
NOTE: Gynecomastia in individuals less than 16 years of age generally will resolve on its own. Therefore, mastectomy for gynecomastia is not indicated for these individuals and is considered cosmetic.
Mastectomy for gynecomastia is considered cosmetic and, therefore, non-covered for any other indication.
19300 |
|
|
|
|
|
|
Nipples, Inverted, Correction may be considered medically necessary when performed in an attempt to restore the ability to breast feed.
Correction of inverted nipples is considered cosmetic and, therefore, non-covered for any other indication.
19355 |
|
|
|
|
|
|
Nipple Tattooing may be considered medically necessary when ANY of the following criteria are met:
Nipple tattooing is considered cosmetic and, therefore, non-covered for any other indication
11920 |
11921 |
19350 |
19499 |
|
|
|
Otoplasty may be considered medically necessary when performed to improve hearing impairment, whether the ears are absent or deformed from trauma, surgery, disease, or congenital defect. Hearing impairment is defined as a loss of AT LEAST 15 decibels outside the normal hearing range in the affected ear(s) documented by audiogram. (Note: degree of hearing loss refers to the severity of the loss. Normal range or no hearing loss = 0dB to 20dB.)
Otoplasty is considered cosmetic and, therefore, non-covered for any other indication.
69300 |
|
|
|
|
|
|
Port Wine Stain Treatment may be considered medically necessary for port wine stains on the face and neck.
Treatment of port wine stains on the trunk or extremities is considered cosmetic and, therefore, non-covered.
17106 |
17107 |
17108 |
|
|
|
|
Rhinoplasty may be considered medically necessary when ANY of the following criteria are met:
Rhinoplasty is considered cosmetic and, therefore, non-covered for any other indication.
20912 |
30400 |
30410 |
30420 |
30430 |
30435 |
30450 |
Rhytidectomy (Meloplasty, Face Lift) may be considered medically necessary when functional impairment exists as a result of a disease state (e.g., facial paralysis).
Rhytidectomy is considered cosmetic and, therefore, non-covered for any other indication.
15824 |
15825 |
15826 |
15828 |
15829 |
|
|
Rosacea Treatment any non-pharmacological treatment method, including but not limited to: laser and light therapy [e.g., intense pulsed light (IPL), dermabrasion, chemical peels, surgical debulking, and electrosurgery] may be considered medically necessary when functional impairment exists and pharmacologic therapy, specific for the treatment of rosacea, has failed or is contraindicated.
Rosacea treatment is considered cosmetic and, therefore, non-covered for any other indication.
17110 |
17111 |
17999 |
96900 |
|
|
|
Scar Revision may be considered medically necessary when correcting scars and keloids resulting from an accident or when functional impairment exists.
Scar revision treatment is considered cosmetic and, therefore, non-covered for any other indication.
15780 |
15786 |
|
|
|
|
|
Other Procedures
The following procedures can be performed for either cosmetic or reconstructive
purposes. If there are no procedure specific guidelines associated with a
listed procedure below, the procedure may be classified as reconstructive only
when there is documented functional impairment:
G0429 |
Q2026 |
Q2028 |
15788 |
15789 |
15792 |
15793 |
15832 |
15833 |
15834 |
15835 |
15836 |
15837 |
15838 |
15839 |
15876 |
15877 |
15878 |
15879 |
17340 |
17360 |
17999 |
19316 |
36468 |
|
|
|
|
Refer to Medical Policy G-20, Actinic Keratosis, for additional information.
Refer to Medical Policy S-36, Removal of Skin Lesions, for additional information.
Refer to Medical Policy S-45, Repair of Lacerations, for additional information.
Refer to Medical Policy S-55, Surgical Treatment of Varicose Veins, for additional information.
Refer to Medical Policy S-74, Covered Suction Assisted Lipectomy Services, for additional information.
Refer to Medical Policy S-129, Mastectomy and Reconstructive Surgery, for additional information.
Refer to Medical Policy S-184, Gender Reassignment Surgery, for additional information.
Non-Covered Diagnosis Codes for Procedure Codes 17000, 17003, 17004, and 96900
L70.0 |
L70.1 |
L70.2 |
L70.3 |
L70.4 |
L70.5 |
L70.8 |
L70.9 |
L71.0 |
L71.1 |
L71.8 |
L71.9 |
L73.0 |
|
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.