068 Form

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Medical Policy Plastic Surgery Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History
• Endnotes Policy Number: 068 BCBSA Reference Number: N/A Related Policies

• Benign Skin Lesions, #707 • Blepharoplasty, Blepharoptosis Repair and Brow Ptosis Repair, #740 • Chemical Peels, #732 • Dermatologic Applications of Photodynamic Therapy, #463
• Gender Affirming Services (Transgender Services), #189
• Laser Treatment of Active Acne, #461 • Nonpharmacologic Treatment of Rosacea, #462 • Orthognathic Surgery, #179 • Reconstructive Breast Surgery/Management of Breast Implants, #428 • Surgical and Non-Surgical Treatment of Gynecomastia, #661

Policy1

Services Described in this Policy • Congenital deformities • Nose • Facial Plastic Surgery • Reconstructive Surgery • Ears • Hair: Removal • Skin Treatments • Panniculectomy • Chest Wall Deformity • Eyes

• Musculoskeletal transplants

This policy describes those situations where plastic surgery services are considered MEDICALLY NECESSARY in order to restore physical function, or to correct a physical problem resulting from accidents, injuries, or birth defects. Complications following a cosmetic surgery procedure may be considered MEDICALLY NECESSARY when the treatment of the complication itself is medically necessary to restore bodily function or correct a physical impairment.

For all procedures only the initial reconstructive repair is covered, unless the procedure is normally done in stages.

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Note: Subscriber certificates exclude coverage for cosmetic services.

Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

CONGENITAL AND DEVELOPMENTAL DEFORMITIES IN CHILDREN Congenital and developmental deformities in children may be considered MEDICALLY NECESSARY when the defects are severe or debilitating including but not limited to: • Deforming hemangiomas
• Pectus excavatum
• Syndactyly • Macrodactylia. See below for further specifics regarding each body part.

The child does not have to have been covered under BCBSMA at the time of birth.

Note: Laser treatments of port-wine stains or hemangiomas of the face and neck are covered.
Authorizations are not required for laser treatments of port wine stains/hemangiomas on the face and neck in children and adults.

RECONSTRUCTIVE SURGERY Reconstructive surgery may be considered MEDICALLY NECESSARY when it is performed to: • Improve or give back bodily function, OR
• Correct a functional impairment that was caused by o an accidental injury, OR o a birth defect, OR
o a prior surgical procedure or disease, OR
• Correct scarring after accidental face and neck injuries.

HIV-associated lipodystrophy Per State Mandate2 Chapter 233 of the Acts of 2016, An Act Relative to HIV Associated Lipodystrophy Syndrome Treatment, the following services are covered. Coverage is subject to a statement from a treating provider that the treatment is necessary for correcting, repairing or ameliorating the effects of HIV associated lipodystrophy syndrome.

• Medical or drug treatments to correct or repair disturbances of body composition caused by HIV associated lipodystrophy syndrome including, but are not limited to: o Reconstructive surgery, such as suction assisted lipectomy, other restorative procedures and
o Dermal injections or fillers for reversal of facial lipoatrophy syndrome.

HAIR Hair removal, including electrolysis and laser, may be considered MEDICALLY NECESSARY if ingrown hairs are responsible for 2 or more painful cysts. Electrolysis and/or laser hair removal must be performed by a licensed and/or certified provider.

Hair removal, including electrolysis and laser, may be considered MEDICALLY NECESSARY after treatment of a pilonidal cyst to prevent recurrence.

SKIN TREATMENT Dermabrasion may be MEDICALLY NECESSARY for dermal restoration after previous surgery or injury.

Pulsed dye laser treatments of hypertrophic scars may be considered MEDICALLY NECESSARY for the treatment of symptomatic hypertrophic scars when there is documented functional impairment.

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Removal of excess skin may be considered MEDICALLY NECESSARY after significant weight loss in individuals with stable weight with recurrent documented rashes or non-healing ulcers, or when there is a documented functional impairment, such as significant difficulty with activities of daily living.

Rhytidectomy may be considered MEDICALLY NECESSARY for the correction of functional impairment from facial nerve palsy.

Treatment of scars, either by surgery or intralesional steroid injection, may be considered MEDICALLY NECESSARY when the scar tissue interferes with normal bodily function or when the scar causes pain.

Lipoma removal may be considered MEDICALLY NECESSARY when the lipoma is painful and causes functional limitations with activities of daily living based on its location.

NOSE Rhinoplasty may be considered MEDICALLY NECESSARY when there is airway obstruction due to deformities, disease, congenital abnormality, or previous therapy that does not respond to septoplasty alone.

Reconstructive rhinoplasty may be considered MEDICALLY NECESSARY for a causally related accidental injury.

EARS Otoplasty may be considered MEDICALLY NECESSARY for unilateral or bilateral congenital absence of the ear (anotia) or severe microtia (for example, grade III).

FACE

Facial plastic surgery may be considered MEDICALLY NECESSARY: • for initial restoration of appearance after accidental injury, • to restore bodily function or correct a functional impairment caused by: o An accident, OR o A birth defect, OR o A prior surgical procedure (even if the original procedure was cosmetic, as long as the complication resulted in physical functional impairment), OR o Disease.

CHEST/TORSO/ABDOMEN Congenital chest wall deformity may be considered MEDICALLY NECESSARY to correct pectus excavatum when there is: • A Haller index of 3.2 or greater (which is suggested to be a future predictor of cardiovascular compromise), OR • Risk of impending cardiovascular or respiratory compromise due to the magnitude of deformity, based upon the requesting physician’s clinical judgment.

Congenital chest wall deformity may be considered MEDICALLY NECESSARY to correct pectus carinatum when there is:
• Risk of impending cardiovascular or respiratory compromise due to the magnitude of deformity, based upon the requesting physician’s clinical judgment.

Diastasis Recti repair is considered NOT MEDICALLY NECESSARY.

Liposuction or Lipectomy is considered MEDICALLY NECESSARY when the purpose of the procedure is to remove fat in order to correct a functional impairment that was caused by: • An accidental injury, OR • A birth defect, OR

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• A prior surgical procedure, OR • Disease, including, but not limited to lipedema.

A panniculectomy is considered reconstructive (not cosmetic) and considered MEDICALLY NECESSARY after *significant weight loss when it is performed to remove a hanging abdominal panniculus of at least grade 2 severity with associated symptoms such as: • Recurrent or refractory skin problems including: a. Skin necrosis, recalcitrant to conventional wound healing interventions such as debridement
OR b. Recurrent skin infections refractory to medical treatment (e.g., dressing changes; topical, oral, or systemic antibiotics, corticosteroids, or systemic antifungals) *Recurrent is defined as at least two incidents in a 12month period
OR c. Intertriginous skin rashes or skin ulcerations that show no signs of healing after at least 8 weeks of active care under the direction of a dermatologist or wound care specialist OR • Shoulder, neck or back pain is sufficiently severe to interfere with activities of daily living.

Panniculectomy should be deferred to at least twelve months post-bariatric surgery, with stable weight for at least the past 6 months.

**Significant weight loss is defined as meeting one of the following criteria: • A body mass index (BMI) of 30 or less. • A documented weight loss of 100 pounds or more. • A weight loss of 40% or more of the patient's excess body weight.

Note: Submission of medical record documentation is required that indicates the nature of the skin condition, treatments attempted and response to treatment. Pre-operative photographs should be submitted to confirm the individual’s condition.

Panniculectomy in all other situations including repeat procedures is considered NOT MEDICALLY NECESSARY

Abdominoplasty is considered cosmetic and NOT MEDICALLY NECESSARY.

MUSCULOSKELETAL Musculoskeletal transplants may be considered MEDICALLY NECESSARY: • As an initial repair after accidental injury, OR • To restore bodily function or correct a functional impairment caused by: an accidental injury; a birth defect; or a prior surgical procedure or disease.

Labiaplasty may be considered MEDICALLY NECESSARY for the treatment of recurrent documented rashes, non-healing ulcers, or functional impairment in basic activities of daily living.

Plastic surgery or reconstructive surgery for indications other than the above listed criteria is NOT MEDICALLY NECESSARY.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient

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• For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is required when indicated in the code tables below. Commercial PPO and Indemnity Prior authorization is required when indicated in the code tables below.

Requesting Prior Authorization Using Authorization Manager Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.
To ensure the service request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources Refer to our Authorization Manager page for tips, guides, and video demonstrations. CPT Codes / HCPCS Codes / ICD-10 Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity: CPT Codes: Hair Removal
CPT codes: Code Description 17380 Electrolysis epilation, each 30 minutes

CPT Codes: HIV-associated lipodystrophy CPT codes: Code Description 15770 Graft; derma-fat-fascia 15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) 15828 Rhytidectomy; cheek, chin, and neck 15829 Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap 15838 Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad 15839 Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area 15876 Suction assisted lipectomy; head and neck 15877 Suction assisted lipectomy; trunk

HCPCS Codes

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HCPCS codes: Code Description Q2026 Injection, Radiesse, 0.1 ml Q2028 Injection, sculptra, 0.5 mg G0429 Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy)

CPT Codes: Dermabrasion CPT codes: Code Description 15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis) 15781 Dermabrasion; segmental, face 15782 Dermabrasion; regional, other than face 15783 Dermabrasion; superficial, any site (eg, tattoo removal) Note: The dermabrasion codes above require outpatient prior authorization for all products.

CPT Codes: Pulsed Dye Laser Treatments CPT codes: Code Description 17110 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions 17111 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions

CPT Codes: Removal of Excess Skin CPT codes: Code Description 15832 Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh 15833 Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg 15834 Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip 15835 Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock 15836 Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm 15837 Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand 15838 Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad 15839 Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area Note: The removal of excess skin codes above requires outpatient prior authorization for all products.

CPT Codes: Labiaplasty CPT codes: Code Description 56620 Vulvectomy simple; partial

CPT Codes: Scars CPT codes: Code Description 11900 Injection, intralesional; up to and including 7 lesions 11901 Injection, intralesional; more than 7 lesions Note: The injection codes above require outpatient prior authorization for Medicare HMO Blue products.

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CPT Codes: Rhinoplasty CPT codes: Code Description 30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip 30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip 30420 Rhinoplasty, primary; including major septal repair 30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work) 30435 Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) 30450 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) Note: The rhinoplasty codes above require outpatient prior authorization for all products.

CPT Codes: Congenital Chest Wall Deformity CPT codes: Code Description 21740 Reconstructive repair of pectus excavatum or carinatum; open 21742 Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy 21743 Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy

CPT Codes: Panniculectomy
CPT codes: Code Description 15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy

CPT Codes: Lipectomy/Liposuction CPT codes: Code Description 15876 Suction assisted lipectomy; head and neck 15877 Suction assisted lipectomy; trunk 15878 Suction assisted lipectomy; upper extremity 15879 Suction assisted lipectomy; lower extremity

Note: The lipectomy/liposuction codes above require outpatient prior authorization for Commercial HMO and PPO products.

CPT Codes: Rhytidectomy CPT codes: Code Description 15824 Rhytidectomy; forehead 15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) 15826 Rhytidectomy; glabellar frown lines 15828 Rhytidectomy; cheek, chin, and neck 15829 Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap

CPT Codes: Otoplasty CPT codes: Code Description 69300 Otoplasty, protruding ear, with or without size reduction

The following CPT code is considered not medically necessary for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

CPT Code: Abdominoplasty CPT codes: Code Description

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15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

Policy History Date Action 5/2026 Clarified coding information 11/2025 Panniculectomy statement clarified. Added not medically necessary statement and clarified the definition of significant weight loss. 6/2025 Cleft lip/palate statement removed. Coverage is determined by the subscriber certificate. Panniculectomy criteria revised. Clarified coding information. 10/2024 Policy clarified. Hair transplants removed. Coverage is determined by the subscriber certificate. 10/1/2024. 5/2024 Policy clarified. Laser treatments of port-wine stains or hemangiomas of the face and neck are covered. Authorizations are not required for laser treatments of port wine stains/hemangiomas on the face and neck in children and adults. 12/2023 Policy clarified. New medically necessary statement added for hair removal to prevent pilonidal cyst recurrence. 9/2023 Policy clarified to include prior authorization requests using Authorization Manager.
8/2023 Policy clarified. Prior authorization (PA) table was updated to indicate that PA is required for liposuction/lipectomy for:
• Commercial PPO and EPO
• Commercial Managed Care (HMO and POS).
The PA table was also updated to include a separate column for Commercial Indemnity.

Policy clarified. Medically necessary statements on Liposuction or Lipectomy updated to state: including, but not limited to lipedema under Disease (last bullet). 3/2023 Policy revised. New medically necessary statement on lipoma removal. Clarified coding information. Effective 3/1/2023

Policy clarified. The following surgical procedures were transferred to the new medical policy #179, Orthognathic Surgery.
• Mandibular or maxillary osteotomy/plasty for prognathism or micrognathism with documented severe handicapping malocclusion. • Other osteotomy/plasty for congenital conditions that cause severe facial or cranio- facial deformities including but not limited to Crouzon’s syndrome, Treacher Collin’s dysostosis, or Romberg’s disease. • Mentoplasty.

Cleft Lip/Cleft Palate Repair statement for members <18 years of age clarified.
11/2022 Clarified prior authorization information 6/2022 Prior authorization information clarified for PPO Plans. Effective 6/1/2022. 9/2021 Policy updated to include medically necessary language for adolescent and adult intersex individuals whose anatomy does not conform to typical binary notions of male or female and/or is not congruent with their gender identity. Effective 9/2021.

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1/2021 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
3/2020 Medically necessary statement on removal of excess skin clarified to include functional impairment, such as significant difficulty with activities of daily living. 5/2019 Age criteria to correct pectus excavatum and pectus carinatum removed. Effective 5/1/2019. 12/2018 Abdominoplasty is considered cosmetic and not medically necessary. Effective 12/1/2018. 8/2018 Medically necessary statements regarding State Mandate Chapter 233 of the Acts of 2016, An Act Relative to HIV Associated Lipodystrophy Syndrome Treatment clarified.
8/10/2018 6/2018 Clarified coding information. 9/2017 Medically necessary criteria for tattooing of the areola as part of nipple reconstruction clarified. Not medically necessary tattoo removal or application criteria clarified.
9/1/2017
2/2017 Clarified coding information. 1/2017 Clarified coding information. 11/2016 Policy updated to include mandated coverage for reconstructive services to correct or repair disturbances of body composition caused by HIV associated lipodystrophy syndrome. Effective 11/8/2016. 5/2016 Liposuction criteria updated to indicate when it is medically necessary. Clarified coding information. Effective 5/1/2016.
11/2015 Policy #460 Laser Treatment of Port Wine Stains retired. 11/1/2015 1/2016 Chest wall deformity medically necessary criteria clarified. Effective 1/1/2016. 10/2015 Medical policy ICD-10 remediation: Formatting, editing and coding updates.
o Blepharoplasty, Blepharoptosis Repair and Brow Ptosis Repair - new medical policy describing medically necessary and not medically necessary indications transferred to policy #740, Blepharoplasty, Blepharoptosis Repair and Brow Ptosis Repair. 10/1/2015 o Chemical Peels - new medically necessary statements transferred to policy #732, Chemical Peels. 10/1/2015 o Destruction of Actinic Keratoses - medically necessary statement retired. This treatment is considered medically necessary. 10/1/2015 o Excision or Shaving of Rhinophyma - ongoing medically necessary indications transferred to policy #462, Nonpharmacologic Treatment of Rosacea. 10/1/2015 o Injection of Acne Cysts - medically necessary statement retired. This treatment is considered medically necessary. 10/1/2015 o Laser Treatment of Active Acne - ongoing investigational statement transferred to policy #461, Treatment of Active Acne. 10/1/2015 o Nonpharmacologic Treatment of Rosacea - ongoing medically necessary and investigational indications transferred to policy #462, Nonpharmacologic Treatment of Rosacea. 10/1/2015 o Orthodontics and Dental Services - statements retired. Coverage for orthodontic services is determined by subscriber certificate and through dental plan. 10/1/2015 o Wigs and Hair Prosthesis - statement removed. Coverage is determined by the subscriber certificate. 10/1/2015

References

1. Parrett BM, Donelan MB. Pulsed dye laser in burn scars: Current concepts and future directions. Burns (2009), doie: 10.1016/j.burns.2009.08.015
2. Donelan MB, Parrett BM, Sheridan, RL. Pulsed Dye Laser Therapy and Z-Plasty for Facial Burn Scars: The Alternative to Excision. Ann Plast Surg 2008 May; 60 (5) 480-6.
3. Haedersdal M, Togsverd-Bo K, Wiegell SR et al. Long-pulsed dye laser versus long-pulsed dye laser- assisted photodynamic therapy for acne vulgaris: a randomized controlled trial. J Am Acad Dermatol 2008; 58(3):387-94.

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4. Practice Parameter for Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients. Practice Parameter for Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients. American Society of Plastic Surgeons. Published July 24, 2017. Accessed January 28, 2025.

   Endnotes

   1 Based on expert local opinion 2 Based on State Mandate Chapter 233 of the Acts of 2016, An Act Relative to HIV Associated Lipodystrophy Syndrome Treatment. Effective August 10, 2016.