Cosmetic and Reconstructive Procedures Form

1

Cosmetic and Reconstructive Procedures - Medical Policy
Effective: June 1, 2024 Policy Number:

UM974POL

Approval Date: 4/29/2024

Line(s) of Business:

Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Cosmetic and reconstructive procedures are defined as follows by the American Medical Association and the American Society of Plastic Surgeons:

Reconstructive surgery is an established service when it involves the restoration of a patient to a normal functional status, or when it is done to repair a defect arising from congenital defects, developmental abnormalities, trauma, infection, involutional defects, tumors or disease. It may be a therapeutic option when indicated.

Cosmetic surgery is performed solely to preserve or enhance appearance or self-esteem. It is considered not medically necessary.

There are areas of overlap where cosmetic procedures may have a reconstructive component, and reconstructive procedures may have a cosmetic component. These procedures are categorized, and benefits are authorized, based upon the fundamental purpose of the procedure.

If the intended service relates to gender reassignment services, please refer to the HNE

Gender Affirming Services Medical Policy.

For abdominal panniculectomy, please refer to the HNE

Abdominal Panniculectomy Medical Policy.

For blepharoplasty, please refer to the HNE

Blepharoplasty Medical Policy.

For pectus excavatum and pectus carinatum, please refer to the HNE

Reconstructive Repair of Pectus Excavatum or Pectus Carinatum Medical Policy.

2

For HIV-associated lipodystrophy please refer to the HNE

Treatment of Lipodystrophy Syndrome Medical Policy.

For breast surgery, please refer to either the HNE

Breast Reconstruction Medical Policy, the HNE Female Breast Reduction Medical Policy, or the HNE Surgical Treatment of Gynecomastia Medical Policy.

For rhinoplasty, please refer to the HNE

Rhinoplasty Medical Policy.

For Bio-engineered skin and soft tissue substitutes (e.g., Hyalomatrix, AlloDerm, Apligraf, Epicel, etc.), see separate HNE

Skin and Soft Tissue Substitutes Medical Policy.

For photochemotherapy, phototherapy, and laser treatment, please refer to the HNE

Photochemotherapy, Phototherapy, and Laser Treatments Medical Policy.

 Line of Business

Commercial:
Refer to criteria under Policy section in this medical policy.

Medicaid – BeHealthy:
Refer to criteria under Policy section in this medical policy. There are no MassHealth guidelines for the cosmetic procedures addressed by this policy.

Medicare:
Refer to criteria under Policy section in this medical policy. Medicare does not have a National Coverage Determination (NCD) or a Local Coverage Determination (LCD) for the cosmetic procedures addressed by this policy. Per the Medicare Benefit Policy Manual chapter 15 §120, cosmetic surgery or expenses incurred in connection with such surgery, for the sole purpose of improving one’s appearance, is not covered.

Policy

Reconstructive Surgery:
The goal of reconstructive surgery must be to correct an abnormality in order to restore physiological function to the extent possible. As such, for reconstructive surgery to be considered medically necessary, there must be a reasonable expectation that the procedure will improve the functional impairment or used as part of an indicated therapy.

A procedure is considered cosmetic and a benefit exclusion if the only desired and/or expected benefits would be emotional or psychological, unless the procedure is repairing a genetic defect.

Complications from Cosmetic Procedures:

HNE will review procedures intended for correcting complications from a cosmetic procedure, whether the original procedure was medically necessary or a non-covered service.

Treatment for complications from a cosmetic procedure are considered medically necessary when
 the repair procedure is reconstructive in nature; AND

3

 the treatment of the complication is medically necessary.

The purpose of the surgery should generally be performed to improve function but may also be done to approximate normal appearance.

Congenital Deformities in Children:
We consider procedures to correct congenital and developmental deformities in children to be medically necessary when defects are severe or debilitating. These include cleft lip, cleft palate, or both, and additional defects of the septum related to other cleft deformities, deforming hemangiomas, pectus excavatum and others.

I. HEAD:

A. Malar Augmentation, with Prosthetic Material

1. Additional documentation required:
    History of present illness and history and physical report demonstrating physical impairment caused by disease, trauma, and/or congenital defect

2. We consider the procedure medically necessary for the following:
    As part of facial reconstruction after accidental injury, trauma, or disease (e.g., infection, tumor of the face); OR
    To correct a significant congenital anomaly.

3. We consider the procedure cosmetic and, therefore, not covered as a benefit exclusion for all other indications.

   B. Orthognathic Procedures

4. Additional documentation required:
    History of present illness and history and physical report demonstrating physical impairment caused by disease, trauma, and/or congenital defect  Pictures and x-rays illustrating the deformity, both frontal and profile
    Additionally, for those under 18 years of age, one of the following must be submitted as evidence of puberty completion: o Documented Tanner stage IV or V for members aged 15-18; AND
   o Stable height measurements for 6 months; OR
   o Puberty completion as shown on wrist radiograph.

5. We consider orthognathic procedures medically necessary for the following:
    Health New England has adopted InterQual criteria for all members over the age of 18.
    For members under 18 years of age: o Prognathism or micrognathism with documented severe handicapping malocclusion with any of the following:
    Deep impinging overbite with severe soft tissue damage
    Impacted permanent anterior teeth
    Class III malocclusion
    Overjet of at least 4 mm
    Overbite of at least 2 mm
    Difficulty chewing or biting food

4

 Difficulty swallowing
 Open bite (space between the upper and lower teeth when the mouth is closed)
 Inability to make lips meet without straining
 Severe mandibular atrophy
o Diagnosis of Crouzon’s syndrome
o Diagnosis of Treacher Collins’ dysostosis
o Diagnosis of Romberg’s Disease with severe facial deformity
o Other significant cranio-facial abnormalities related to structure and growth or trauma that include:
 Cleft palate deformities
 Other birth defects
 Severe traumatic deviations causing severe handicapping malocclusion referenced above

3. LeFort II and III Osteotomy (all ages) for any of the following may be used alone or in combination with other orthognathic procedures:
    Correction of midface deformities due to trauma or congenital anomalies
    Treatment of Class II and Class III malocclusions

4. We consider the orthognathic procedure cosmetic and, therefore, not covered as a benefit exclusion for the following:
    In the absence of severe handicapping malocclusion, trauma, congenital anomalies not listed above; OR
    When intended to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem

   NOTE: Mentoplasty/genioplasty for familial chin deformities or “weak chin” performed for cosmetic reasons are not covered as they are a benefit exclusion.

   NOTE: Orthodontics, including orthodontics performed as adjunct to orthognathic surgery are not covered as they are a benefit exclusion.

   C. Otoplasty – Reconstruction of external auditory canal

5. Additional documentation required:
    History and physical examination
    Photographs – We consider the procedure medically necessary for the following:
   o Surgically correctable congenital malformation, trauma, surgery, infection, or other process that is causing hearing loss. [Audiogram must demonstrate a loss of at least 15 decibels in the affected ear(s).]
   o To restore a significantly abnormal external ear or auditory canal related to trauma, tumor, surgery, infection, or congenital malformation (e.g., atresia).
   o Congenital absence (anotia) or underdevelopment of the external ear (microtia).

6. We consider otoplasty cosmetic and, therefore, not covered as a benefit exclusion for all other indications, including the following (not an all-inclusive list):
    Keloids (unless qualifying under criteria for Keloids below)  Clefts  To reshape the ear due to consequences of ear piercing or ear gauging in the absence of significant physical dysfunction.
    “Lop ears” or protruding ears.

5

D. Temporomandibular Joint Dysfunction

1. For those plans which cover treatment for temporomandibular joint dysfunction:  Health New England has adopted InterQual criteria.  For members under 18 years of age, the request will be reviewed on a case-by-case basis.

   E. Surgery for conditions that do not meet above criteria are considered Experimental and Investigational.

   II. SKIN:

   A. Cryotherapy for the Treatment of Acne Vulgaris

2. Additional documentation required:  History of present illness and history and physical report  Photograph demonstrating affected area

3. We consider the procedure medically necessary when both of the following are met:
    Active acne  Documented evidence of failure of a trial of topical retinoid treatment, topical antibiotic therapy, and oral antibiotic therapy

4. We consider the procedure not medically necessary when there has not been a trial of topical retinoid treatment, topical antibiotic therapy, and oral antibiotic therapy

5. We consider the procedure cosmetic and, therefore, not covered as a benefit exclusion for the following:
    In the absence of active acne  To remove acne scarring to improve the patient’s appearance and self-esteem

   B. Dermabrasion – Surgical procedure for removal of scars on the skin by using sandpaper or mechanical methods on the frozen epidermis

6. Additional documentation required:
    History of present illness and history and physical report  Date of accident or injury, if applicable  Photograph demonstrating affected area

7. We consider the procedure medically necessary for any of the following:
    Restoration following previous injury or surgery with severe disfigurement or functional and physiological impairment; OR  Documented evidence of 10 or more superficial basal cell carcinomas, actinic keratoses, or other pre-malignant skin lesions that have failed topical retinoid treatment, topical chemotherapeutic agents, and cryotherapy

8. We consider the procedure not medically necessary for the treatment of all other conditions.

9. We consider the procedure cosmetic and, therefore, not covered as a benefit exclusion to treat the following:
    Scarring from acne vulgaris
    Skin wrinkling

6

 Rhinophyma
 Tattoo Removal

C. Scar and Keloid Revision

1. Additional documentation required:
    History of present illness and history and physical report
    Preoperative photograph
    Date of accident or injury, if applicable
    Description of and CPT® coding for planned staged procedure following acute repair, within two years of previous stage or initial primary repair

2. We consider the procedure medically necessary for the following:
    To treat functional impairment or pain with the expectation that treatment can be reasonably expected to improve the impairment

3. We consider the procedure cosmetic and, therefore, not covered as a benefit exclusion for the following:
    In the absence of any functional impairment, pain, or expectation that treatment can be reasonably expected to improve the impairment  To correct any consequences related to piercing or gauging

   D. Tattooing of the Skin

4. Additional documentation required:
    Clinical statement indicating tattooing is in conjunction with medically necessary procedures (e.g., breast reconstruction after mastectomy)

5. We consider the procedure medically necessary with approval of primary procedure (e.g., breast reconstruction following mastectomy).

6. We consider the following cosmetic and, therefore, not covered as a benefit exclusion:  Placement, removal or coverage of decorative tattoos  Tattooing of the skin for color differential as a result of vitiligo  Salabrasion  Dermabrasion

   III. OTHER:

   A. NOTE: For treatment of HIV-associated lipodystrophy as required by Massachusetts statute, please refer to HNE Treatment of Lipodystrophy Medical Policy.

   B. Collagen Injections – Subcutaneous injection of filling material to restore physiologic function, EXCLUDING those conditions associated with HIV-associated lipodystrophy

7. Additional documentation required:
    History of present illness and history and physical report demonstrating physical impairment caused by disease, trauma, and/or congenital defect

8. We consider the procedure medically necessary for the following:

7

 Documented evidence of significant functional impairment and the expected functional improvement following correction of a physical impairment caused by disease, trauma, and/or congenital defect

3. We consider the procedure cosmetic and, therefore, not covered as a benefit exclusion when performed in the absence of any functional impairment and intended to improve the patient’s appearance and self-esteem.

   C. Lipectomy – The excision of a mass of subcutaneous adipose tissue from the body

4. Suction-assisted lipectomy is considered medically necessary when the lipectomy is performed as part of the treatment of lipedema.

5. Suction-assisted lipectomy MAY be considered medically necessary when performed as a secondary procedure adjunct to an authorized reconstructive procedure.

6. We consider the following procedures cosmetic and, therefore, not covered as a benefit exclusion for the following:
    Low-level laser (cold laser) therapy (e.g., Zerona)
    Excision, excessive skin and subcutaneous tissue for any part of the body unless expressly addressed in the certificate of coverage  Suction-assisted lipectomy as a primary procedure

   D. Testicular Prosthesis Insertion – Insertion of a prosthesis to replace a testicle due to congenital absence or surgical removal

7. Additional documentation required:
    Clinical statement by physician that testicle was either congenitally absent or was surgically removed (due to disease or trauma)
    Date and nature of proposed surgery

8. We consider the procedure medically necessary for the following:
    Insertion of a testicular prosthesis may be considered medically necessary due to congenital or acquired absence of a testicle.

   E. Procedures Related to the Genitalia

9. If the intended service relates to gender affirming care, please refer to the HNE Gender Affirming Services Medical Policy.

10. For procedures EXCLUDING gender affirmation: a. Procedures including, but not limited to, the following:  Vaginoplasty – Reconstruction or rejuvenation of the vagina
     Clitoroplasty – Reconstruction or reduction of the clitoris
     Labiaplasty – Reconstruction or reduction of the labia
     Vulvectomy – Removal of part or all of the vulva
     Vulvoplasty – Reconstruction of the vulva
     Phalloplasty – Penis lengthening surgery  Scrotoplasty - Surgery to the scrotal sack

11. We consider the above procedures medically necessary for any of the following:

8

 A congenital anomaly is present
 With a medical diagnosis of cancer affecting the area  The area is affected by severe infection and/or trauma or causing severe functional impairment

4. The request must include documented evidence of significant functional impairment, except in the case of cancer removal and debulking or severe infection requiring removal for treatment, and the expected functional improvement following correction of physical impairment.

5. We consider the procedure cosmetic and, therefore, not covered as a benefit exclusion when the above medically necessary criteria are not met and the procedure is performed in order to improve the patient’s appearance and self-esteem.

   IV. COSMETIC EXCLUSIONS:

   A. Cosmetic procedures are a specific exclusion under the subscriber’s contract.

   B. The following is a list that includes, but is not limited to, procedures that are considered cosmetic and, therefore, non-covered services:

    Botox injections for cosmetic purposes  Breast implants not performed during reconstruction after breast cancer  Fat transfer or fat grafts (except where referred to Breast Surgery and Gender Affirming Services)  Rhytidectomy (facelift) for the signs of aging  Hair transplants  Diastasis recti correction – Surgery to correct a separation of the lower abdominal muscles in the midline  Ear or body piercing – Ear and body piercing are considered cosmetic and not medically necessary for all reasons.  Hair procedures – Hair transplant for alopecia (including male pattern alopecia) or hair removal (temporary or permanent) for all indications  Laser treatment of telangiectasia  Excision of excessive skin and subcutaneous tissue, and tightening (plication) of underlying structures (includes abdominoplasty, correction of diastasis rectus, lipectomy (when not addressed above) and umbilical transposition) of the chest, abdomen, thigh, leg, hip, buttocks, arm, forearm, hand, neck (submental fat pad) and all other areas not specified. NOTE: For Abdominal Panniculectomy, refer to the HNE Abdominal Panniculectomy Medical Policy.  Suction-assisted removal of fatty tissue (lipectomy) in the head, neck, trunk, upper extremity or lower extremity  Breast lift (mastopexy), except when a necessary component of reconstruction of breasts following breast surgery  Surgery to improve the appearance of the ear (otoplasty)  Cosmetic procedures and supplies that are not reconstructive

   Policy Guidelines and Definitions

   Requests for all procedures listed in this policy should be accompanied by the following documentation:

    The name and date of the proposed surgery

9

 Preoperative photographs, if appropriate and illustrative
 Date of accident or injury, if applicable
 History of present illness and/or conditions including diagnoses
 Documentation of functional impairment, pain or significant anatomic variance
 How the treatment can be reasonably expected to improve the functional impairment
 If applicable, the description of and CPT® coding for planned staged procedures following acute repair or initial primary repair

Additional documentation required is listed with the specific procedure.

Coding Guidance

Code
Description
Covered with PA unless otherwise indicated

0552T Not Covered Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional

11921 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm

11922 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure)

11950 Subcutaneous injection of filling material (eg, collagen); 1 cc or less MassHealth covered with diagnosis of lipodystrophy associated with, or secondary to, HIV only.
11951 Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc 11952 Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc 11954 Subcutaneous injection of filling material (eg, collagen); over 10.0 cc 11960 Insertion of tissue expander(s) for other than breast, including subsequent expansion

15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)

15781 Dermabrasion; segmental, face

15782 Dermabrasion; regional, other than face Not covered for MassHealth 15783 Dermabrasion; superficial, any site (eg, tattoo removal) Not covered for MassHealth 15786 Abrasion; single lesion (eg, keratosis, scar) Not covered for MassHealth 15787 Abrasion; each additional 4 lesions or less (List separately in addition to code for primary procedure) Not covered for MassHealth 15824 Rhytidectomy; forehead Not covered for Medicare or MassHealth 15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) Not covered for Medicare or MassHealth 15826 Rhytidectomy; glabellar frown lines Not covered for Medicare or MassHealth

10

Code
Description
Covered with PA unless otherwise indicated

15828 Rhytidectomy; cheek, chin, and neck Not covered for Medicare or MassHealth 15829 Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap Not covered for Medicare or MassHealth 15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy

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

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) Not Covered for MassHealth 15876 Suction assisted lipectomy; head and neck Not covered for Medicare, MassHealth covered with diagnosis of lipodystrophy associated with, or secondary to, HIV only 15877 Suction assisted lipectomy; trunk Not covered for Medicare, MassHealth covered (1) with diagnosis of lipodystrophy associated with, or secondary to, HIV, or (2) as a gender affirming related service 15878 Suction assisted lipectomy; upper extremity 15879 Suction assisted lipectomy; lower extremity 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

17340 Cryotherapy (CO2 slush, liquid N2) for acne Not Covered for MassHealth 17360 Chemical exfoliation for acne (eg, acne paste, acid) Not Covered for MassHealth 17380 Electrolysis epilation, each 30 minutes Not covered for Medicare

11

Code
Description
Covered with PA unless otherwise indicated

21120 Genioplasty; augmentation (autograft, allograft, prosthetic material)

21121 Genioplasty; sliding osteotomy, single piece Not Covered for MassHealth 21122 Genioplasty; sliding osteotomies, 2 or more osteotomies (e.g., wedge excision or bone wedge reversal for asymmetrical chin) Not Covered for MassHealth 21123 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)

21125 Augmentation, mandibular body or angle; prosthetic material

21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft)

21137 Reduction forehead; contouring only

21138 Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft)

21139 Reduction forehead; contouring and setback of anterior frontal sinus wall

21141 Reconstruction midface, LeFort I; single piece, segment movement in any direction (e.g., for Long Face Syndrome), without bone graft

21142 Reconstruction midface, LeFort I; two pieces, segment movement in any direction, without bone graft

21143 Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, without bone graft

21145 Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts)

21146 Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted unilateral alveolar cleft)

21147 Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (e.g., ungrafted bilateral alveolar cleft or multiple osteotomies

21150 Reconstruction midface, LeFort II; anterior intrusion (e.g., Treacher-Collins Syndrome)

21151 Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining Autografts

21154 Reconstruction midface, LeFort III; (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I

12

Code
Description
Covered with PA unless otherwise indicated

21155 Reconstruction midface, LeFort III; (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I

21159 Reconstruction midface, LeFort III; (extra and intracranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I

21160 Reconstruction midface, LeFort III; (extra and intracranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I

21172 Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts)

21175 Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts)

21179 Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material)

21180 Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts)

21188 Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts)

21193 Reconstruction of mandible rami; horizontal, vertical, C, or L osteotomy; without bone graft

21194 Reconstruction of mandible rami; horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft)

21195 Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation

21196 Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation

21198 Osteotomy, mandible, segmental

21199 Osteotomy, mandible, segmental; with genioglossus advancement

21206 Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)

21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)

21209 Osteoplasty, facial bones; reduction

21210 Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)

21215 Graft, bone; mandible (includes obtaining graft)

13

Code
Description
Covered with PA unless otherwise indicated

21230 Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)

21235 Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)

21270 Malar augmentation, prosthetic material

21244 Reconstruction of mandible, extraoral, with transosteal bone plate (e.g., mandibular staple bone plate)

21245 Reconstruction of mandible or maxilla, subperiosteal implant; partial Not Covered for MassHealth 21246 Reconstruction of mandible or maxilla, subperiosteal implant; complete Not Covered for MassHealth 21247 Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (e.g., for hemifacial microsomia)

21248 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial Not Covered for MassHealth 21249 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete Not Covered for MassHealth 21255 Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)

21256 Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia)

21260 Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach

21261 Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and extracranial approach

21263 Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement

21267 Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach

21268 Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and extracranial approach

21275 Secondary revision of orbitocraniofacial reconstruction

21280 Medial canthopexy (separate procedure)

21282 Lateral canthopexy

21295 Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approach

21296 Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach

54660 Insertion of testicular prosthesis (separate procedure)

14

Code
Description
Covered with PA unless otherwise indicated

55175 Scrotoplasty; simple MassHealth covered for gender affirming related services only 55180 Scrotoplasty; complicated 56805 Clitoroplasty for intersex state

58999 Unlisted procedure, female genital system (nonobstetrical)

56620 Vulvectomy simple; partial

56625 Vulvectomy simple; complete 56630 Vulvectomy, radical, partial

56631 Vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy

56632 Vulvectomy, radical, partial; with bilateral inguinofemoral lymphadenectomy

56633 Vulvectomy, radical, complete

57335 Vaginoplasty for intersex state

67911 Correction of lid retraction

67912 Correction of lagophthalmos, with implantation of upper eyelid lid load (eg, gold weight)

67950 Canthoplasty (reconstruction of canthus)

69300 Otoplasty, protruding ear, with or without size reduction

S8948 Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes Not payable for Medicare or MassHealth CPT® Copyright 2024 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

American Society of Plastic Surgeons, “ASPS Recommended Insurance Coverage Criteria for Third- Party Payers,” https://www.plasticsurgery.org/for-medicalprofessionals/health-policy/recommended- insurance-coverage-criteria. December 2022

American Society of Plastic Surgeons, “Cosmetic Procedures,” https://www.plasticsurgery.org/cosmetic-procedures. December 2022

American Society of Plastic Surgeons, “Reconstructive Procedures,” https://www.plasticsurgery.org/reconstructive-procedures. December 2022

15

Karimipour, Darius J. et al, “Microdermabrasion: An Evidence-Based Review,” Plastic and Reconstructive Surgery, 125 (1) p.372-377, January 2010.

Strauss, John MD et al., “Guidelines of care for acne vulgaris management,” J Am Acad Dermatol, 2007; 56:651-63.

Feldman SR, Fleischer AB Jr. Progression of actinic keratosis to squamous cell carcinoma revisited: clinical and treatment implications. Cutis. 2011 Apr;87(4):201-7.

Uhlenhake EE. Optimal treatment of actinic keratoses. Clin Interv Aging. 2013;8:29-35. doi: 10.2147/CIA.S31930

Alerić Z, Bauer V. Skin growths of the head and neck region in elderly patients--analysis of two five year periods in General Hospital Karlovac, Croatia. Coll Antropol. 2011; 35 Suppl 2:195-198.

Feldman SR, Fleischer AB Jr. Progression of actinic keratosis to squamous cell carcinoma revisited: clinical and treatment implications. Cutis. 201; 87(4):201-207.

InterQual, CP:Procedures.

https://www.changehealthcare.com/clinical-decision-support/interqual

Lanssens S, Ongenae K. Dermatologic lesions and risk for cancer. Acta Clin Belg. 2011; 66(3):177- 185.

Park, JU and Baik, SH. Classification of Angle Class III malocclusion and its treatment modalities. Int J Adult Orthod Orthognath Surg, 2001; 1 (1) 19-29.

Rigel DS, Stein Gold LF. The importance of early diagnosis and treatment of actinic keratosis. J Am Acad Dermatol. 2013; 68(1 Suppl 1):S20-27.

Sabiston DC Jr. Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 15th ed., (Philadelphia: W.B. Saunders, Co., 1997), PP. 1326 & 1327.

Tannous ZS, Mihm MC Jr, Sober AJ, Duncan LM. Congenital melanocytic nevi: clinical and histopathologic features, risk of melanoma, and clinical management. J Am Acad Dermatol. 2005;52(2):197-203.

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 6/2023 New Policy 1/2024 Added Line of Business Section. 4/2024 Updated Definitions, Line of Business Section, and criteria in section E4, updated references.

16

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.