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 is considered cosmetic and therefore non-covered.

Canthopexy may be considered medically necessary when performed for any ONE of the following conditions:

• Presence of corneal or conjunctival staining; or
• Mucous membrane changes; or
• Documentation of epiphora and poor closure of the lids; or
• Entropion; or
• Ectropion; or
• Bell's palsy; or
• Dermatochalasis.

Canthopexy for any other indication is considered cosmetic and, therefore, non-covered.

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.

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.

Dermabrasion may be considered medically necessary when correcting defects resulting from an accident or when functional impairment exists.

Dermabrasion for any other indication is considered cosmetic and, therefore, non-covered.

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.

Earlobe surgery for any other indication is considered cosmetic and, therefore, non-covered.

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.

Facial surgery for any other indication is considered cosmetic and, therefore, non-covered.

Hair Removal (Permanent) by any method (e.g., by electrolysis) may be considered medically necessary when BOTH of the following criteria are met:

• When performed to prevent the recurrence of pilonidal cysts; and
• When ingrown hairs are responsible for repeated painful cysts, targeted hair removal is appropriate.

Hair removal not meeting the criteria as indicated in this policy is considered cosmetic and therefore non-covered.

NOTE: Electrolysis and laser hair removal performed for hirsutism is classified as cosmetic and, therefore, not covered.

Hair Transplant may be considered medically necessary when performed as a result of injury or burn.

Hair transplant for any other indication is considered cosmetic and, therefore, non-covered.

Mammoplasty, Augmentation may be considered medically necessary when ANY of the following criteria are met:

• When unilateral breast aplasia is present; or
• Following extirpative surgery for benign disease (e.g., subcutaneous mastectomy with either immediate or delayed [second stage] prosthesis); or
• When a reconstructive procedure is performed following previous radical surgery for malignant disease; or
• When breast hypoplasia (affected breast) is associated with Poland's syndrome.

Augmentation mammoplasty not meeting the criteria as indicated in this policy is considered cosmetic and therefore non-covered.

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.

Mammoplasty, Reduction/Breast Reduction may be considered medically necessary when ALL of the following criteria are met:

• The individual has AT LEAST a one (1)-year history of significant signs and symptoms that interfere with normal activities, including AT LEAST two (2) of the following:
  • Back, neck or shoulder pain not related to other causes such as arthritis, poor posture, acute strains, etc.; or
  • Clinical, non-seasonal submammary intertrigo; or
  • Significant shoulder grooving or shoulder point tenderness; or
  • Breast hypertrophy; or
  • Paresthesias of hands/arms; and
• Conservative measures, such as those below, have been tried and have not resulted in significant improvement:
  For back, neck, or shoulder pain, AT LEAST three (3) months of conservative treatment including;
  • Appropriate support bra; and
  • Non-steroidal, anti-inflammatory drugs (NSAIDS) (if not contraindicated); and
  • Exercises and heat or cold application; and
• For chronic submammary intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing), AT LEAST (3) months of conservative therapy including:
  • Appropriate hygiene; and
  • Appropriate medical treatment (including appropriate prescription medications); and
  • Utilization of an appropriate support bra; and
• Candidates for breast reduction must be greater than or equal to 18 years of age. Requests for an individual under 18 years old will be considered on an individual basis, due to the sensitive nature of performing procedure on the developing breast; and
• Average weight of tissue planned to be removed in each breast is above the 22nd percentile as referenced on the Schnur Sliding Scale based on the individual’s body surface area (BSA). Please see the table attachment at the end of the policy for the Schnur Table.

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 not meeting the criteria as indicated in this policy is considered cosmetic and therefore non-covered.

Mastectomy For Gynecomastia
Mastectomy for gynecomastia is considered reconstructive when ALL of the following criteria are met:

• The individual meets the criteria for Grade II, III, or IV; and
• One of the following:
  • For boys 16, 17, and 18 years old, whose body mass index (BMI) is less than the 75th percentile for age; i.e., a BMI of 22.7 for age 16, a BMI of 23.4 for age 17, and a BMI of 24.1 for age 18; or
  • For men over age 18, and a BMI of less than or equal to 25; and
• When pathologic gynecomastia (e.g., hypogonadism, endocrine disorders, metabolic disorders, neoplasms, and male breast cancer) and pharmacologic gynecomastia (i.e., gynecomastia induced by pharmacological agents, including but not limited to, cimetidine, digitalis, methadone, marijuana, clomiphene, chemotherapeutic agents, anti-retroviral agents, herbal remedies, chlorpromazine, and anabolic steroids) have been excluded.

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.

Mastectomy for gynecomastia not meeting the criteria as indicated in this policy is considered cosmetic and therefore non-covered.

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.

Nipples, Inverted, Correction may be considered medically necessary when performed in an attempt to restore the ability to breast feed.

Correction of inverted nipples for any other indication is considered cosmetic and, therefore, non-covered.

Nipple Tattooing may be considered medically necessary when ANY of the following criteria are met:

• When performed as part of a reconstructive procedure following radical surgery (e.g., mastectomy for benign or malignant disease); or
• When performed following an injury (e.g., burn).

Nipple tattooing  not meeting the criteria as indicated in this policy is considered cosmetic and therefore non-covered.

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 not meeting the criteria as indicated in this policy is considered cosmetic and therefore non-covered.

Panniculectomy may be considered medically necessary when ALL of the following criteria are met:

• Preoperative photographs document that the panniculus or fold hangs at or below the level of the symphysis pubis; and
• Preoperative photographs must document the individual’s name; and
• The medical records document that the panniculus or fold causes chronic intertrigo (dermatitis on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs or remains refractory to appropriate medical therapy (including appropriate prescription medications) over a period of three (3) months.

NOTE: The individual must be 18 months postoperative following bariatric surgery.

Panniculectomy not meeting the criteria as indicated in this policy is considered cosmetic and therefore non-covered.

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. 

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 for any other indication is considered cosmetic and, therefore, non-covered.

Rosacea Treatment utilizing 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 BOTH of the following criteria are met:

• Functional impairment exists; and
• Pharmacologic therapy, specific for the treatment of rosacea, has failed or is contraindicated.

Rosacea treatment not meeting the criteria as indicated in this policy is considered cosmetic and therefore non-covered.

Scar Revision may be considered medically necessary when correcting scars and keloids resulting from an accident or illness or when functional impairment exists.

Scar revision treatment for any other indication is considered cosmetic and, therefore, non-covered.

Umbilectomy

Umbilectomy may be considered medically necessary for ALL the following:

• Management of infected urachal cysts; or
• Presence of umbilical hernia causing discomfort or complications; or
• Recurrent infections or abscesses at the navel site; or
• Umbilical tumors or other growths.

Umbilectomy for any other indication is considered cosmetic and, therefore non-covered.

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:

• Chemical exfoliation for acne; or
• Chemical peel; or
• Correction of diastasis recti abdominis; or
• Excision, excessive skin, thigh, leg, hip, buttock, arm, forearm, or hand, submental fat pad, other area; or
• Mastopexy; or
• Microdermabrasion; or
• Procedures/products/services via any treatment modality (e.g., laser, cryotherapy) performed solely for the treatment of post-acne scarring; or
• Salabrasion; or 
• Suction assisted lipectomy done solely for cosmetic purposes; or 
• Temporary hair removal (e.g., waxing, laser).