Point32 Reconstructive and Cosmetic Surgery(Eff. beginning 1.1.24) Form

The Plan may provide coverage for reconstructive surgery and procedures when they meet Medical Necessity Guidelines

and are determined to be Medically Necessary as defined below.

I. Procedures included in this policy with The Plan MEDICAL NECESSITY guidelines:

• A. General Reconstructive and Cosmetic Surgery+
• B. Redundant Skin – Surgical Removal (includes Abdominoplasty/Panniculectomy)*+
• C. Hemangioma and Port Wine Stain Treatments*
• D. Hair Removal by Laser or Electrolysis
• E. Labiaplasty
• F. Breast Reconstruction

II. Procedures included in this policy that require an InterQual SmartSheet:

• A. Breast Implant Removal*^+
• B. Gynecomastia: Surgical Correction by Mastectomy, Male*^+
• C. Reduction Mammoplasty for Symptomatic Macromastia, Female*^+
• D. Rhinoplasty*^+
• E. Scar Revision^

Procedures for which Harvard Pilgrim Health Care uses InterQual criteria ^

Procedures for which Tufts Health Plan uses InterQual criteria +

Procedures for which Tufts Health One Care utilizes guidance from the Centers for Medicare and Medicaid Services

The Plan uses guidance from the Centers for Medicare and Medicaid Services (CMS) and MassHealth for coverage determinations for its Dual Product Eligible plan members.

CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs) and documentation included in the Medicare manuals and MassHealth Medical Necessity Determinations are the basis for coverage determinations.

For Tufts Health One Care plan members, the following is used:

• General Cosmetic and Reconstructive Surgery,
• Rhinoplasty,
• Gynecomastia,
• Breast Implant Removal,
• Breast Reduction, and
• Panniculectomy (as evident by the + above)

LCD - Cosmetic and Reconstructive Surgery (L39051) (cms.gov)

Redundant Skin MassHealth Guidelines for Medical Necessity Determination for Excision of Excessive Skin and Subcutaneous Tissue | Mass.gov

Scar Revision :

The use of InterQual provides guidance for the coverage of these additional Scar Revision procedures Evidence is also sufficient for coverage of Cosmetic and Reconstructive Surgery for Hemangioma, Port Wine Stain treatment, Hair Removal and Labiaplasty. These procedures are identified in the medical literature and endorsed by various medical society guidelines.

The use of this supplemented criteria in the utilization management process will ensure access to evidence based clinically appropriate care.

See References section below for all evidence accessed in the development of these criteria.

Clinical Guideline Coverage Criteria

The following are for Procedures with The Plan Medical Necessity Guidelines

Reconstructive and Cosmetic Surgery

2procedures after mastectomy are covered for:

• all stages of reconstruction of the breast on which the mastectomy was performed
• surgery and reconstruction of the other breast to produce a symmetrical appearance

Limitations

Reconstructive surgery may not be covered for a congenital defect or birth anomalies that have not resulted in significant functional impairment.

Cosmetic surgery or procedures are not covered at any time.

Cosmetic means to change or improve appearance.

HIV-associated lipodystrophy syndrome CPT codes:

• 15836 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm
• 15839 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area
• 15877 | Suction assisted lipectomy; trunk
• 15878 | Suction assisted lipectomy; upper extremity
• 15879 | Suction assisted lipectomy; lower extremity

ICD-10 CM Codes:

• B20 - Human immunodeficiency virus [HIV] disease
• E88.1 - Lipodystrophy, not elsewhere classified

Redundant Skin — Surgical Removal Coverage Guidelines

The Plan may authorize coverage for the surgical removal of redundant skin if the Member meets ONE of the following criteria: (Documentation, a letter of medical necessity is required)

Redundant skin is defined as large skin folds that are the result of a massive weight loss. Redundant skin can be present on several parts of the body. A pannus is an overhanging apron of redundant, abdominal skin. Panniculectomy is the surgical removal of the pannus. Brachioplasty is the term used to describe the surgical removal of the redundant skin from the upper arms.

1. Skin necrosis, recalcitrant to conventional wound healing interventions such as debridement
2. Recurrent skin infections requiring systemic antibiotics or systemic antifungals
   • Recurrent to be defined as at least two incidences in a 12-month period
3. Intertriginous skin rashes or skin ulcerations that show no signs of healing after at least 8 weeks of care under the direction of a Dermatology Specialist (Note: Submission of the Dermatology Medical Record Documentation Required)

Additional Coverage Guidelines

In cases where the redundant skin is the result of a medical weight loss, the weight loss must have been maintained for at least six months before Member will be considered for a procedure based on the above criteria.

In cases where the redundant skin is the result of bariatric surgery, The Plan will not cover the procedure until eighteen (18) months after the surgery is performed, the weight loss has been maintained for at least six (6) months and no more than an additional twenty (20) pound loss is anticipated before the Member will be considered for a procedure based on the above criteria.

Reconstructive and Cosmetic Surgery Limitations

The Plan will not cover a request for redundant skin removal if it is for any one of the following reasons as it is not considered medically necessary to do so:

1. An abdominoplasty or panniculectomy for:
   • Treatment of neck or back pain
   • Repair of an abdominal laxity or diastasis recti
   • Treatment of psychological or psychosocial issue related to redundant skin
   • When the procedure is performed at the time of an additional abdominal or gynecological surgery unless it meets the medical necessity guidelines above
2. Brachioplasty or thighplasty, etc.
3. The Plan will not cover the surgical removal of redundant skin or body contouring for cosmetic purposes only.

*Note for Tufts Health Together and Tufts Health One Care: Brachioplasty or thighplasty may be medically necessary when there is significant impaired physical function or recurrent skin infection.

However, only in rare circumstances would excessively skin and subcutaneous tissue in the arms, thighs, or buttocks, etc. cause significant impaired physical function or recurrent skin or soft tissue infections. Typically, these procedures are performed to improve appearance and are therefore cosmetic in nature.

The following CPT codes require prior authorization:

• 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
• 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

Hemangioma and Port Wine Stain Treatments

Hemangioma is a blood-filled birthmark or benign tumor consisting of closely packed small blood vessels. Commonly found during infancy, it first grows, and then may spontaneously disappear in early childhood without treatment. Nevus flammeus, also known as a port wine stain, is a flat capillary hemangioma that is present at birth and that varies from pale red to deep reddish purple. These lesions most often occur on the face. The depth of the color depends on whether the superficial, middle, or deep dermal vessels are involved. On the face the lesion persists and develops a thick, verrucous, nodular surface.

Coverage Guidelines Hemangioma Treatment

The Plan may authorize coverage of invasive treatment for cutaneous congenital hemangiomas, with a limit of 6 treatments, for Members when ONE of the following criteria are met:

1. Hemangioma is visible (above clothing) on the face, neck, or ears; OR
2. Hemangioma compromises the function of vital structures, (e.g., vocal cord, auditory impairment); OR
3. Hemangioma is symptomatic (i.e., has a history of recurrent bleeding, ulceration, or infection); OR
4. Hemangioma is pedunculated (attached with a narrow, stalk-like base); OR
5. Hemangioma is associated with Kasabach-Merrit Syndrome.

Port Wine Stain Treatment

The Plan may authorize coverage of laser treatment of a Port-Wine Stain (nevus flammeus), with a limit of 6 treatments, for Members when ONE of the following criteria are met:

1. Lesion is visible (above clothing) on the face, neck, or ears OR
2. Lesion has been subject to recurrent bleeding, ulceration, orinfection, OR
3. Lesion results in obstructed vision and treatment is medically necessary to prevent complications.

The following CPT codes require prior authorization:

• 17106 | Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); less than 10 sq. cm
• 17107 | Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); 10.0 to 50.0 sq. cm
• 17108 | Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); over 50.0 sq. cm

Hair Removal by Laser or Electrolysis

Coverage Guidelines

The Plan may authorize coverage for hair removal with laser or electrolysis, by a board-certified dermatologist or treating licensed provider, when the Member meets one of the following criteria:

1. Planned gender affirming genital surgery

1. Gender affirming face and neck hair removal
2. Recurrent infected cyst, hair follicle infections, or after surgical treatment of pilonidal sinus disease to prevent reinfection

Note: Prior authorization for planned genital gender affirming surgery must be in place in order for The Plan to review a request for hair removal. Refer to the Medical Necessity Guidelines for Gender Affirming Services for more information.

Authorization for hair removal from face and neck only may be medically necessary when the Member meets criteria outlined in the Medical Necessity Guidelines for Gender Affirming Services.

Limitations

The following CPT codes require prior authorization:

• 17380 | Electrolysis epilation, each 30 minutes Unlisted procedure, skin, mucous membrane and
• 17999 | subcutaneous tissue {when specified as permanent hair removal by laser}

ICD-10 Description

• Codes F64-F64.9 | Gender identity disorder
• Personal history of sex reassignment
• Note: The above ICD-10-CM codes are subject to state regulations as applicable for Tufts Health Together Plans.
• N90.60 Unspecified hypertrophy of vulva
• Childhood asymmetric labium majus enlargement
• N90.69 Other specified hypertrophy of vulva

E. Labiaplasty

Coverage Guidelines

The Plan may authorize coverage for labiaplasty for a diagnosis of hypertrophy in Members aged 18 and older when there is documentation of one or more of the following:

• Interference in basic activities and/or functions OR
• Recurrent rashes or non-healing ulcers in the affected area, despite conservative topical treatment OR
• Dyspareunia

Limitations

The Plan will not cover labiaplasty for cosmetic purposes.

The following CPT code requires prior authorization when billed with one of the diagnosis codes listed below:

• 56620 | Vulvectomy simple; partial

F. Breast Reconstruction

*Applicable to Harvard Pilgrim Health Care Commercial Members

Coverage Guidelines

The Plan may authorize coverage for breast reconstruction when documentation confirms the following:

1. Member has undergone a medically necessary mastectomy or lumpectomy procedure
1. Documentation confirms a diagnosis or history of breast cancer

Limitations

The Plan considers breast reconstruction as not medically necessary for all other conditions.

In addition, The Plan does not cover:

• Cosmetic procedures (e.g., mastopexy, correction of inverted nipple) that are not part of an authorized post-mastectomy breast reconstruction procedure

Codes

The following codes require prior authorization:

• CPT Code 19316 | Mastopexy
• CPT Code 19340 | Insertion of breast of
• CPT Code 19342 | implant on same day mastectomy (ie, immediate)
• Insertion or replacement of breast implant on separate day from mastectomy
• CPT Code 19355 | Correction of inverted nipples
• CPT Code 19357 | Tissue in breast expander placement reconstruction, including subsequent expansion(s)
• CPT Code 19361 | Breast reconstruction; with latissimus dorsi flap
• CPT Code 19364 | Breast with free reconstruction; flap (eg, TRAM, DIEP, SIEA, GAP flap)
• CPT Code 19367 | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap
• CPT Code 19369 | Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap

The following are for procedures that require an InterQual SmartSheet or Subset Codes

• A. Breast Implant Removal InterQual - Breast Implant Removal

The following CPT codes require prior authorization:

• Code 19328 | Removal of intact mammary implant
• Code 19330 | Removal of mammary implant material
• Code 19370 | Open periprosthetic capsulotomy, breast
• Code 19371 | Periprosthetic capsulectomy, breast

• B. Gynecomastia: Surgical

Correction by Mastectomy, Male InterQual Reduction Mammoplasty Male

The following CPT codes require prior authorization:

• Code 19300 | Mastectomy for gynecomastia

InterQual Reduction Mammoplasty Male

InterQual Reduction Mammoplasty, Reconstructive and Cosmetic Surgery

The Plan Modifications to InterQual Criterion section

(20) of the InterQual SmartSheet, for ‘Breast reduction of contralateral breast post mastectomy’ does not require prior authorization.

Codes

The following CPT codes require prior authorization:

• 19318 | Reduction mammoplasty

D. Rhinoplasty

Codes

• InterQual SmartSheet Rhinoplasty

The following CPT codes require prior authorization:

• 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: If rhinoplasty is being requested for the indication of gender affirmation, please refer to Medical Necessity Guidelines for Gender Affirming Services.

Note: For the diagnosis of cleft lip and/or cleft palate, the following CPT codes are covered without prior authorization:

• 30460 | Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only
• 30462 | Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies

Reconstructive and Cosmetic Surgery

Scar Revision

Note: Applicable to Tufts Health Plan Products ONLY. For Harvard Pilgrim Health Care Coverage please refer to the Removal of Benign Skin Lesions MNG. There are three InterQual SmartSheets that represent procedures for scar revision.

• Criterion section 1(A) of the InterQual SmartSheet Scar Revision for \'Mismatch of vertical edges\' does not meet the findings requirement because it is considered cosmetic.

The Plan may authorize Keloid Excision (fractional laser ablation) for Members less than 18 years of age when:

• + InterQual criteria for the procedure is met

Limitations

These are:

• e Scar Revision
• The Plan will not cover scar revision done for cosmetic purposes, for example: only to alter the appearance of the scar.
• e Scar Contracture Release

Codes

e Keloid Excision

The following any of the CPT code(s) require prior authorization when performed with ICD-10-CM codes listed below:

• CPT Code | Description
• 0479T | Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first 100 cm2 or part thereof, or 1% of body surface area of infants and children
• 0480T | Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area of infants and children, or part thereof (List separately in addition to code for primary procedure)
• 11042 | Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less
• 11043 | Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq. cm or less
• 11400 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less
• 11401 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm
• 11402 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm
• 11403 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm
• 11404 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm

cm or less Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm

Reconstructive and Cosmetic Surgery

• CPT Code 11420 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm
• CPT Code 11421 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm
• CPT Code 11422 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm
• CPT Code 11423 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm
• CPT Code 11424 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm
• CPT Code 11426 | Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm
• CPT Code 11440 | Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less
• CPT Code 11441 | Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm
• CPT Code 11442 | Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm
• CPT Code 11443 | Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cm
• CPT Code 11444 | Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 3.1 to 4.0 cm
• CPT Code 11446 | Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm

• CPT Code 13100 | Repair, complex, trunk; 1.1 cm to 2.5 cm
• CPT Code 13101 | Repair, complex, trunk; 2.6 cm to 7.5 cm
• CPT Code 13102 | Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure)
• CPT Code 13120 | Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm
• CPT Code 13121 | Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm
• CPT Code 13122 | Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure)
• CPT Code 13131 | Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm
• CPT Code 13132 | Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm
• CPT Code 13151 | Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm
• CPT Code 13152 | Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm

ICD-10-CM Code(s):

• Code L90.5 | Scar conditions and fibrosis of skin
• Code L91.0 | Hypertrophic scar

The Plan considers the following cosmetic and reconstructive procedures as not medically necessary:

The Plan considers the following cosmetic and reconstructive procedures as not medically necessary:

1. Chemical Peel (dermal and epidermal)
2. Dermabrasion
3. Injection of dermal filling materials for cosmetic purposes (e.g., treatment of acne or chicken pox scars, or facial wrinkles)
4. Microdermabrasion
5. Removal of skin tags
6. Removal of decorative tattoo
7. Shaving or removal of a benign, asymptomatic epidermal or dermal lesions
8. 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)