Anthem Blue Cross Connecticut ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities Form

This document addresses a variety of surgical procedures of the trunk or groin that may be considered medically necessary, cosmetic or reconstructive in nature.

Note: Please see these documents for related topics:

• CG-SURG-12 Penile Prosthesis Implantation
• CG-SURG-71 Reduction Mammaplasty
• CG-SURG-88 Mastectomy for Gynecomastia
• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Note: For information regarding excision of excess abdominal skin, please see CG-SURG-99 Panniculectomy and Abdominoplasty

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant functional impairment AND the procedure can be reasonably expected to improve the functional impairment.

Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect.

Note: Not all benefit contracts/certificates include benefits for reconstructive services as defined by this document. Benefit language supersedes this document.

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those which are primarily intended to preserve or improve appearance.

Position Statement

A.    Brachioplasty:

Brachioplasty is considered medically necessary when done in the presence of a significant functional impairment (for example, redundant or excessive skin is interfering with activities of daily living or causing persistent dermatitis, cellulitis, or skin ulcerations) and the impairment persists despite optimal medical management (for example, topical or systemic treatments for infection) and the procedure is reasonably expected to improve that significant functional impairment.

Brachioplasty is considered cosmetic and not medically necessary when done in the absence of a significant functional impairment or when not expected to improve a significant functional impairment.

B.    Buttock/Thigh Lift:

Buttock or thigh lifts are considered medically necessary when there is a significant functional impairment (for example, redundant or excessive skin is interfering with activities of daily living or causing persistent dermatitis, cellulitis, or skin ulcerations) and the impairment persists despite optimal medical management (for example, topical or systemic treatments for infection) and the procedure is reasonably expected to improve that significant functional impairment.

Buttock and thigh lifts are considered cosmetic and not medically necessary when done in the absence of a significant functional impairment or when not expected to improve a significant functional impairment.

C.    Congenital Abnormalities:

Correction of congenital abnormalities of the trunk and groin are considered medically necessary when there is evidence of a significant functional impairment and the procedure can be reasonably expected to improve the functional impairment.

Correction of congenital abnormalities of the trunk and groin that are a significant variation from normal are considered reconstructive in nature.

In the absence of a significant functional impairment or significant variation from normal, correction of congenital abnormalities is considered cosmetic and not medically necessary.

D.    Lipectomy/Liposuction:

Lipectomy or liposuction is considered medically necessary in individuals with documented lymphedema (primary or secondary, for example, related to surgical mastectomy) when all of the following criteria are met (1 through 5):

1. Signs and symptoms have not responded to at least 3 consecutive months of optimal medical management, including one or more of the following:
   1. Compression garments; or
   2. Manual lymph drainage; or
   3. Complex/complete decongestive therapy (CDT);
      and
2. For each anatomical region being considered for treatment, either of the following criteria are met:
   1. There is documented significant functional impairment as a direct result of change in limb volume from lymphedema accumulation (for example, difficulty ambulating, performing activities of daily living, or loss of function coincident with the volume change); or
   2. There are documented medical complication(s) as a result of lymphedema (for example, severe recurrent cellulitis or severe neurological symptoms [for example, numbness, tingling or paresthesia]), and both of the following criteria are met for the complication(s):
      1. Not amenable to conservative management; and
      2. Significant enough to warrant surgical intervention; 
         and
3. Lipectomy or liposuction is reasonably expected to improve the functional impairment (for example, volume reduction of extremity circumferences is expected to result in a significant improvement in mobility); and
4. The plan of care is to wear compression garments as instructed and continue conservative treatment postoperatively to maintain benefits; and
5. Photographic documentation is consistent with the diagnosis of lymphedema in the affected extremities, including limb asymmetry.

Lipectomy or liposuction is considered medically necessary in individuals with lipedema when all of the following criteria are met (1 through 6):

1. A diagnosis of lipedema has been documented, including all of the following:
   1. Bilateral, symmetrical, disproportionate fatty tissue hypertrophy on the limbs sparing the hands and feet; and
   2. Negative Stemmer sign; and
   3. Marked tendency to bruise or form hematomas; and
   4. Stable limb circumference with weight reduction or caloric restriction (if applicable); and
   5. Pain on pressure and touch;
      and
2. Signs and symptoms have not responded to at least 3 consecutive months of optimal medical management, including both of the following:
   1. Compression garments; and
   2. Manual lymphatic drainage; 
      and
3. For each anatomical region being considered for treatment, either of the following criteria are met:
   1. There is documented significant functional impairment as a direct result of change in limb volume from lipedema (for example, difficulty ambulating or performing activities of daily living); or
   2. There are documented medical complication(s) as a result of lipedema (for example, severe aching discomfort, pain or tenderness, severe maceration, severe recurrent skin infection, or severe venous insufficiency) and both of the following criteria are met for the complication(s):
      1. Not amenable to conservative management; and
      2. Significant enough to warrant surgical intervention;
         and
4. Lipectomy or liposuction is reasonably expected to improve the functional impairment or medical complications (for example, volume reduction of extremity circumferences is expected to result in a significant improvement in mobility); and
5. The plan of care is to wear compression garments as instructed and continue conservative treatment postoperatively to maintain benefits; and
6. Photographic documentation is consistent with the diagnosis of lipedema in the affected extremities, including limb symmetry.

Correction of lymphedema (for example, related to surgical mastectomy) or lipedema using lipectomy or liposuction is considered reconstructive when done to address a significant variation from normal.

Lipectomy or liposuction is considered cosmetic and not medically necessary when the reconstructive criteria in this section are not met or when the medically necessary criteria in this section are not met, including for treatment of obesity in the absence of a documented diagnosis of lymphedema or lipedema.

Notes: Please refer to:

• CG-SURG-99 Panniculectomy and Abdominoplasty for information regarding lipectomy and liposuction of the abdomen.
• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures for information regarding the Women’s Health and Cancer Rights Act of 1998.

E.    Pectus Excavatum/Carinatum:

Surgical repair of a significant pectus excavatum with either an open or a minimally invasive approach (Nuss procedure) is considered reconstructive for individuals with a Haller index (pectus severity index) of greater than or equal to 3.2.

Surgical repair of a significant pectus carinatum is considered reconstructive for individuals with a Haller index (pectus severity index) of less than or equal to 2.0.

Surgical repair of pectus excavatum or carinatum is considered cosmetic and not medically necessary when the criteria above have not been met.

Note:

1. For pectus excavatum the Haller index is calculated by measuring the transverse diameter of the thorax between the internal rib margins, divided by the minimal antero-posterior depth as measured from the internal aspect of the sternum to the anterior cortex of the subjacent vertebral body.
2. For pectus carinatum the Haller index is calculated by measuring the transverse diameter of the thorax between the internal rib margins, divided by the antero-posterior depth as measured from the most anterior level of the sternum to the anterior cortex of the subjacent vertebral body.

F.     Procedures on the Genitalia:

Procedures performed on genitalia when intended to address the sequelae of significant trauma, injury, disease, or congenital defect in the absence of a functional impairment, may be considered reconstructive in nature, including, but not limited to, surgical correction of ambiguous genitalia and buried penis.

Procedures on the external genitalia intended to improve the appearance or enhance sexual performance are considered cosmetic and not medically necessary including, but not limited to, the following:

1. Labia minora reduction;
2. Labia major reshaping;
3. Clitoral reduction;
4. Hymenoplasty;
5. Pubic liposuction or lift;
6. Phalloplasty.

Vaginal rejuvenation or vaginal tightening procedures are considered not medically necessary under all circumstances.