Point32 Skin Reconstructive and Restorative Procedures Form

Harvard Pilgrim HealthCare Medical Policy

Cosmetic and Reconstructive Skin Procedures

StrideSM (HMO) MEDICARE ADVANTAGE

Subject: Cosmetic and Reconstructive Skin Procedures

Authorization: Prior authorization from Harvard Pilgrim StrideSM (HMO) Medicare Advantage is required for the following procedures:

• Hemangioma Treatment
• Port Wine Stain Treatment
• Scar Revision (Surgical Procedures)
• Panniculectomy, and Excision of excess/redundant skin and subcutaneous tissue

When multiple procedures are requested, criteria for each procedure must be met before services are authorized. When bilateral procedures are requested, criteria must be independently met on right and left sides.

Policy and Coverage Criteria: Harvard Pilgrim StrideSM (HMO) Medicare Advantage considers cosmetic and reconstructive skin procedures as medically necessary when documentation confirms ANY of the following when procedure-specific criteria (below) are met:

• The member is experiencing a physical functional impairment related to a medical condition, congenital defect, birth abnormality or complication, OR
• The requested procedure can reasonably be expected to restore functionality and/or resolve associated medical complications, OR
• To repair or restore facial appearance damaged by accidental injury (e.g., repair of significant facial disfigurement following a serious automobile accident).

Harvard Pilgrim StrideSM (HMO) Medicare Advantage does not cover most cosmetic services, and reserves the right to deny coverage for reconstructive services that are not medically necessary.

• Services required to treat a complication that arises as a result of a non-covered cosmetic service are covered only when medically necessary in all other respects.

Harvard Pilgrim StrideSM (HMO) Medicare Advantage considers restorative procedures as medically necessary when documentation confirms the requested procedure is:

• Reasonable and medically necessary based on the member’s condition, complexity of requested service(s), and accepted standards of clinical practice;
• An essential part of active treatment of the member’s medical condition, and ordered under a plan of care established and reviewed regularly by the attending physician caring for the member; and
• Furnished by provider(s) with appropriate state licensure, and accreditation/certification from an appropriate accrediting organization.

Hemangioma Treatment Harvard Pilgrim StrideSM (HMO) Medicare Advantage considers destruction of a cutaneous congenital hemangioma as medically necessary when documentation confirms ANY of the following criteria:

• Hemangioma is visible (above clothing) on the face, neck, or ears; OR

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Cosmetic and Reconstructive Skin Procedures VA03MAR22P

Harvard Pilgrim StrideSM (HMO) policies are based on medical science and relevant information including current Medicare coverage (including National and Local Coverage Determinations), Harvard Pilgrim medical policies, and Harvard Pilgrim StrideSM (HMO) Medicare Advantage Plan materials. These policies are intended to provide benefit coverage information and guidelines specific to the Harvard Pilgrim StrideSM (HMO) Medicare Advantage Plan.

Providers are responsible for reviewing the CMS Medicare Coverage Center guidance; in the event that there is a conflict between this document and the CMS Medicare Coverage Center guidance, the CMS Medicare Coverage Center guidance will control.

• Hemangioma is causing a functional impairment of vital structures (e.g., impaired vision, astigmatism, auditory impairment and secondary speech delay); OR
• Hemangioma is symptomatic (i.e., has a history of recurrent bleeding, ulceration, or infection); OR
• Hemangioma is pedunculated (attached with a narrow, stalk-like base); OR
• Hemangioma is associated with Kasabach-Merritt Syndrome (KMS).

Port Wine Stain Treatment

Harvard Pilgrim StrideSM (HMO) Medicare Advantage considers laser treatment of a Port-Wine Stain (nevus flammeus) as medically necessary when documentation confirms ANY of the following criteria:

• Lesion is visible (above clothing) on the face, neck, or ears; OR
• Lesion has been subject to recurrent bleeding, ulceration, or infection; OR
• Lesion involves the vasculature of the eye and central nervous system, and treatment is medically necessary to prevent complications (e.g., glaucoma, retinal detachment, intellectual disability).

Surgical Scar Revision

Harvard Pilgrim Health Care (HPHC) considers scar revision as medically necessary when documentation confirms ANY of the following criteria:

• Scar is the result of a prior mastectomy or lumpectomy procedure; OR
• Scar is causing a physical functional impairment (e.g., interferes with movement of a joint); OR
• Scar is causing significant symptoms (e.g., intense pain, burning, itching) that cannot be effectively treated with appropriate local and or systemic medications (e.g., analgesics, corticosteroids, antibiotics); OR
• Scar has a history of intermittent and recurrent breakdown that has been refractory to physician-supervised local treatment.

Panniculectomy and Removal of Redundant Skin and Subcutaneous Tissue from Anatomical Areas other than Breast or Abdomen

Harvard Pilgrim Health Care (HPHC) considers panniculectomy procedures as reasonable and medically necessary when documentation confirms ALL the following criteria:

• Member has achieved weight loss of at least 75 lbs.; AND weight loss has resulted in an occlusive overhanging pannus that covers the genitals and upper thigh crease, upper or mid-thigh, or knees and below (Grade 2 or higher on ASPS scale); AND
• EITHER of the following:
  • Weight loss occurred following lifestyle changes (including diet and exercise) or medical intervention, and member's weight has been stable for at least 6 months; OR
  • Weight loss occurred following bariatric surgery, and member's weight has been stable for at least 12 months' post-surgery; AND
• The pannus directly causes ALL of the following:
  • A physical functional impairment that interferes with activities of daily living including physical exercise; AND
  • Persistent symptomatic intertriginous ulcerations or macerations that have been refractory to good personal hygiene and several months of physician-supervised local treatment; AND
    • Documentation must include a detailed description of all physician-supervised skin treatment
  • Recurrent skin infections (i.e., at least 2 episodes within 12 months) that required systemic antibiotics, and are directly related to the pannus
    • Documentation must confirm episodes are refractory to at least a full course of antibiotic treatment
  • Frontal and lateral colored photographs (taken when the patient is standing erect) are required, and must demonstrate the degree of the pannus and any related skin conditions, AND

HPHC Medical Policy
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Cosmetic and Reconstructive Skin Procedures
VA03MAR22P

Harvard Pilgrim StrideSM (HMO) policies are based on medical science and relevant information including current Medicare coverage (including National and Local Coverage Determinations), Harvard Pilgrim medical policies, and Harvard Pilgrim StrideSM (HMO) Medicare Advantage Plan materials.

These policies are intended to provide benefit coverage information and guidelines specific to the Harvard Pilgrim StrideSM (HMO) Medicare Advantage Plan. Providers are responsible for reviewing the CMS Medicare Coverage Center guidance; in the event that there is a conflict between this document and the CMS Medicare Coverage Center guidance, the CMS Medicare Coverage Center guidance will control.

• The requested procedure can reasonably be expected to restore functionality and/or resolve associated medical complications.

Removal of Redundant Skin

Removal of redundant skin (e.g., from thighs, hips, buttocks, and/or arms) is considered medically necessary when documentation confirms ALL the following:

• Member has achieved weight loss of at least 75 lbs.; AND
• EITHER of the following:
  • Weight loss occurred following lifestyle changes (including diet and exercise) or medical intervention, and member's weight has been stable for at least 6 months; OR
  • Weight loss occurred following bariatric surgery, and member's weight has been stable for at least 12 months' post-surgery; AND
• Weight loss has resulted in significant excess/redundant skin or skin folds; AND
• Redundant skin and/or skin folds directly cause ALL of the following:
  • A physical functional impairment that interferes with activities of daily living including physical exercise; AND
  • Persistent symptomatic intertriginous ulcerations or macerations that have been refractory to good personal hygiene and physician-supervised local treatment over a period of several months; AND
    • Documentation must include a detailed description of all physician-supervised skin treatment
  • Recurrent skin infections (i.e., at least 2 episodes within 12 months) that required systemic antibiotics, and are directly related to the redundant skin
    • Documentation must confirm episodes are refractory to at least a full course of antibiotic treatment

Note: Colored photograph documentation demonstrating the degree of skin redundancy must be mailed or emailed to Harvard Pilgrim Health Care as faxed photographs cannot be utilized in making a determination of medical necessity.

Photographic documentation documenting the size, location and characteristics must be mailed or emailed to HPHC. Faxed photos are usually of poor quality, and cannot be utilized in making a determination of medical necessity.

Initial procedures must be requested within 12 months of the initial injury unless documentation confirms a delay is medically necessary to support optimal outcomes. For members over age 16, documentation must confirm that a delay of 12 or more months is medically necessary to support optimal reconstruction, healing, and remodeling.

Exclusions:

Harvard Pilgrim StrideSM (HMO) Medicare Advantage considers cosmetic and reconstructive skin procedures as not medically necessary for all other indications. In addition, Harvard Pilgrim StrideSM (HMO) Medicare Advantage does not cover:

• Abdominoplasty
• Diastasis recti repair
• Hair removal by any method, temporary or permanent, including, but not limited to, electrolysis, waxing, or laser, even if the excessive hair is caused by a medical condition.

Injection of dermal filling materials for cosmetic purposes (e.g., treatment of acne or chicken pox scars, or facial wrinkles)

Laser therapy for treatment of vitiligo that is not on the face, neck, or hands

Microdermabrasion

Panniculectomy or removal of excess/redundant skin for treatment of psychological or psychosocial issues related to redundant skin

HPHC Medical Policy
Page 3 of 5
Cosmetic and Reconstructive Skin Procedures
VA03MAR22P

Harvard Pilgrim StrideSM (HMO) policies are based on medical science and relevant information including current Medicare coverage (including National and Local Coverage Determinations), Harvard Pilgrim medical policies, and Harvard Pilgrim StrideSM (HMO) Medicare Advantage Plan materials. These policies are intended to provide benefit coverage information and guidelines specific to the Harvard Pilgrim StrideSM (HMO) Medicare Advantage Plan. Providers are responsible for reviewing the CMS Medicare Coverage Center guidance; in the event that there is a conflict between this document and the CMS Medicare Coverage Center guidance, the CMS Medicare Coverage Center guidance will control.

• Panniculectomy or removal of excess/redundant skin performed at the time of an additional abdominal or gynecological surgery unless criteria above are met
• Removal of asymptomatic skin tags
• Removal of decorative tattoo
• Shaving or removal of a benign, asymptomatic epidermal or dermal lesions
• Suction lipectomy except as described above
• Surgical removal of redundant skin, or body contouring for cosmetic purposes only
• Treatments for acne scarring including (but not limited to) dermal fillers, surgery, cryotherapy, chemical exfoliation, and laser and light-based therapies (e.g., blue light therapy, pulsed light, diode laser treatment)

Guidelines:

The severity of abdominal deformities is graded as follows (American Society of Plastic Surgeons [ASPS], 2007d):

1. Grade 1: Panniculus covers hairline and mons pubis but not the genitals
2. Grade 2: Panniculus covers genitals and upper thigh crease
3. Grade 3: Panniculus covers upper thigh
4. Grade 4: Panniculus covers mid-thigh
5. Grade 5: Panniculus covers knees and below