Clinical Policy: Cosmetic and Reconstructive Procedures Form

CENTENE® Corporation

Clinical Policy: Cosmetic and Reconstructive Procedures Reference Number: CP.MP.31 Date of Last Revision: 08/24 Coding Implications

                                                     Revision Log

See Important Reminder at the end of this policy for important regulatory and legal information.

Description Reconstructive surgery is performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, surgery, infection, tumors or disease.¹⁶

This policy outlines the medical necessity criteria for cosmetic and reconstructive procedures.

Note: • For criteria applicable to Medicare plans, please see MC.CP.MP.31 Cosmetic and

Reconstructive Procedures.

• This policy should only be used if there is no health plan-adopted nationally recognized

decision support criteria.

• Please refer to CP.MP.95 Gender Affirming procedures for procedures related to

treatment of gender dysphoria.

Policy/Criteria

A.  Intent of the procedure meets one of the following:
    1.  The procedure is performed to improve the function of an abnormal body part caused
        by illness, trauma, or a congenital defect after failure of conservative therapy (unless
        conservative therapy is not standard of care for the condition, or is contraindicated);
    2.  Skin tag removal when located in an area that affects eyesight or in an area of friction
        with documentation of repeated irritation and bleeding (refer to Benefit Plan Contract
        for any coverage restrictions);
    3.  Scar/keloid revision/removal when accompanied by pain unresponsive to
        conservative therapy and is recurrently infected, unstable, friable; or with functional
        impairment;
    4.  Certain reconstructive procedures may be covered if improving appearance is the
        only benefit, e.g. post-mastectomy breast reconstruction. These procedures may
        include, but are not limited to:
        a.  Post-mastectomy, medically necessary lumpectomy, or other medically necessary
            breast surgery resulting in asymmetry; breast reconstruction, including nipple
            reconstruction, tattooing and surgery on contralateral breast to restore symmetry;
        b.  Use of FDA-approved facial dermal injections [Poly-L-Lactic acid (Sculptra™),
            calcium hydroxylapatite microspheres (Radiesse®)] or autologous fat transfers for
            HIV-associated wasting* when meeting both of the following:

II. It is the policy of Health Plans affiliated with Centene Corporation that cosmetic surgery is

not medically necessary and generally not a covered benefit when performed to improve a
patient’s normal appearance and self-esteem. These procedures include, but are not limited
to:
A.  Excision of excessive skin
B.  Body contouring
C.  Body lift
D.  Breast augmentation
E.  Liposuction, excluding lipoma as directed by clinical decision support criteria
F.  Surgery to correct unsatisfactory results from previous cosmetic and/or non-covered
    service
G.  Revision, removal, or replacement of breast implants previously placed for cosmetic
    reasons
H.  Removal of excess skin or body contouring procedures following weight loss or bariatric
    surgery when removal is solely cosmetic
I.  Facial augmentation
J.  Abdominoplasty
K.  Dermabrasion
L.  Skin rejuvenation and resurfacing
M.  Electrolysis, laser hair removal
N.  Hair transplantation, when not performed to correct permanent hair loss caused by
    disease or injury
O.  Tattooing (except when covered for breast reconstruction post-mastectomy)
P.  Injectable filler
Q.  Circumcision revisions done only to improve appearance
R.  Mastopexy (except for breast reconstruction post-mastectomy, medically necessary
    lumpectomy, or other medically necessary breast surgery resulting in significant
    asymmetry)
S.  Correction of inverted nipples
T.  Repair of diastasis recti
U.  Breast reconstruction for fibroadenomas or other benign lesions, unless medically
    necessary per clinical decision support criteria.

Background Reconstructive surgery is performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, previous or concurrent surgeries, trauma, infection, tumors or disease. It is generally performed to improve the functioning of a body part and may or may not restore a normal appearance.² Functional impairment is a health condition in which the normal function of a part of the body or organ system is less than age appropriate at full capacity, such as decreased range of motion, diminished eyesight or hearing, etc. that variably impacts activities of daily living.³

Cosmetic surgery is performed to reshape normal structures of the body in order to improve the appearance and self-esteem of a patient. It is generally considered not medically necessary.¹

Coding Implications This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2023, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

CPT Codes That Support Coverage Criteria

9. Oh SJ, Koh SH, Lee JW, Jang YC. Expanded flap and hair follicle transplantation for reconstruction of postburn scalp alopecia. J Craniofac Surg. 2010;21(6):1737 to 1740. doi:10.1097/SCS.0b013e3181f403cc
10. Yoo H, Moh J, Park JU. Treatment of Postsurgical Scalp Scar Deformity Using Follicular Unit Hair Transplantation. Biomed Res Int. 2019;2019:3423657. Published 2019 May 13. doi:10.1155/2019/3423657
11. Women's Health Care and Cancer Rights Act (WHCRA). Centers of Medicare & Medicaid Services website. https://www.cms.gov/cioio/programs-and-initiatives/other-insurance- protections/whcra_fact sheet Published 1998. Modified 9/6/2023. Accessed June 21, 2024.
12. Nahabedian M. Complications of reconstructive and aesthetic breast surgery. UpToDate. www.uptodate.com Updated April 12, 2023. Accessed June 21, 2024.
13. Lee BT, Agarwal JP, Ascherman JA, et al. Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps. Plast Reconstr Surg. 2017;140(5):651e to 664e. doi:10.1097/PRS.0000000000003768

Important Reminder

This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

CLINICAL POLICY Cosmetic and Reconstructive Procedures

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.

Note: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.