Anthem Blue Cross Connecticut ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck Form

This document describes the cosmetic, reconstructive, and medically necessary uses of a selection of procedures addressing the treatment of abnormalities of the head and neck.

Note: Please see the following documents for additional information:

• ANC.00007 Cosmetic and Reconstructive Services: Skin Related
• ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities
• CG-OR-PR-04 Cranial Remodeling Bands and Helmets (Cranial Orthotics)
• CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift
• SURG.00096 Surgical and Ablative Treatments for Chronic Headaches

Note: This document does not address gender affirming surgery or procedures. Criteria for gender affirming surgery or procedures are found in applicable guidelines used by the plan.

Note:  

• This document does not address septoplasty alone. Please refer to CG-SURG-18 Septoplasty for additional information.
• This document does not address surgical procedures involving the mandible, maxilla (or both) or genioplasty procedures. Please refer to CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery for additional information.

Note: The use of botulinum toxin is not addressed in this document.

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 that are primarily intended to preserve or improve appearance.

Position Statement

A.     Facial Plastic Surgery:

Facial plastic surgery is considered medically necessary when required to correct a significant functional impairment and the procedure can be reasonably expected to improve the functional impairment. Examples include, but are not limited to, reconstructive procedures which correct or improve a significant functional impairment of speech, nutrition, control of secretions, protection of the airway, or corneal protection.

Facial plastic surgery is considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, or treatment of a disease or congenital defect.
Note: The initial restoration may be completed in stages.

Facial plastic surgery is considered cosmetic and not medically necessary when intended to change a physical appearance that would be considered within normal human anatomic variation.

Facial plastic surgery is considered cosmetic and not medically necessary when the medically necessary or reconstructive criteria in this section are not met.

B.     Otoplasty

Otoplasty is considered medically necessary when performed to surgically correct a physical structure or absence of a physical structure that is causing hearing loss, or intended to facilitate the use of a hearing aid or device when both of the following criteria are met:

1. the procedure is reasonably expected to improve the functional impairment; and
2. an audiogram documents a loss of at least 15 decibels in the affected ear(s).

Otoplasty is considered reconstructive when intended to restore a significantly abnormal external ear or auditory canal related to accidental injury, disease, trauma, or treatment of a disease or congenital defect.

Otoplasty is considered reconstructive when intended to restore the absence of the external ear due to accidental injury, disease, trauma, or the treatment of a disease or congenital defect.

Otoplasty is considered cosmetic and not medically necessary when intended to change a physical appearance that would be considered within normal human anatomic variation. Examples include, but are not limited to, repair of ear lobes with clefts or other consequences of ear piercing, or protruding ears.

Otoplasty is considered cosmetic and not medically necessary when the medically necessary or reconstructive criteria in this section are not met.

Otoplasty using a custom-fabricated device, including but not limited to a custom fabricated alloplastic implant, is considered cosmetic and not medically necessary.

C.     Rhinophyma

Excision or shaving of the rhinophyma is considered medically necessary when both of the following criteria are met:

1. the medical record documentation includes evidence of bleeding or infection; and
2. the procedure can be reasonably expected to improve functional impairment as a result of bleeding or infection.

Excision or shaving of the rhinophyma is considered cosmetic and not medically necessary when the medically necessary criteria in this section are not met.

D.     Rhinoplasty or Rhinoseptoplasty (procedure which combines both rhinoplasty and septoplasty)

Rhinoplasty is considered medically necessary when both of the following criteria are met:

1. the medical record documentation includes evidence of the failure of conservative medical therapy for severe airway obstruction from deformities due to disease, structural abnormality, or previous therapeutic process that will not respond to septoplasty alone; and
2. the procedure can be reasonably expected to improve the functional impairment.

Note: Only the initial restorative repair is medically necessary, unless the procedure is completed in stages with healing periods, then all stages are medically necessary.

Note: Rhinoseptoplasty is considered medically necessary when the criteria above for rhinoplasty are met and medically necessary criteria in CG-SURG-18 Septoplasty are also met.

Rhinoplasty is considered reconstructive if there is documented evidence (that is, radiographs or appropriate imaging studies) of nasal fracture resulting in significant variation from normal without functional impairment. The intent of the surgery is to correct the deformity caused by the nasal fracture.

Rhinoseptoplasty is considered reconstructive if there is documented evidence (that is, radiographs or appropriate imaging studies) of nasal and septal fracture resulting in significant variation from normal without functional impairment. The intent of the surgery is to correct the deformity caused by the nasal and septal fracture.

Rhinoplasty or rhinoseptoplasty to modify the shape or size of the nose is considered cosmetic and not medically necessary when the medically necessary or reconstructive criteria in this section are not met.

E.     Rhytidectomy (Face lift)

Rhytidectomy is considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect. Examples include, but are not limited to, significant burns or other significant major facial trauma.

Rhytidectomy is considered cosmetic and not medically necessary when the reconstructive criteria in this section are not met, including, but not limited to, removal of wrinkles, excess skin, or to tighten facial muscles.

F.     Cranial Nerve Procedures  

Transfers, anastomosis or other procedures of the facial nerve or other cranial nerves or their branches are considered medically necessary to correct a significant functional impairment and the procedure can be reasonably expected to improve the functional impairment. Examples of cranial nerve procedures to correct a functional impairment include, but are not limited to, procedures to allow for speech, nutrition, control of secretions, protection of the airway, or corneal protection.

Transfers, anastomosis or other procedures of the facial nerve or other cranial nerves or their branches 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. Examples of significant variation from normal include, but are not limited to, congenital or acquired facial palsy.

Transfers, anastomosis or other procedures of the facial nerve or other cranial nerves or their branches are considered not medically necessary when the medically necessary or reconstructive criteria in this section are not met.

G.     Ear or Body Piercing

Ear or body piercing is considered cosmetic and not medically necessary when performed for any reason.

H.    Frown Lines

Removal of frown lines is considered cosmetic and not medically necessary when performed for any reason, including, but not limited to, the excision or correction of glabella frown lines or forehead lift (cosmetic foreheadplasty).

I.     Neck Tuck (Submental Lipectomy)

Neck tucks are considered cosmetic and not medically necessary when performed for any reason.