Point32 Reconstructive and Cosmetic Surgery Form

Harvard Pilgrim HealthCare Medical Policy

Subject: Reconstructive and Cosmetic Surgery

Authorization: Prior authorization is required for all cosmetic and reconstructive procedures requested for members enrolled in commercial (HMO, POS, and PPO) products.

This policy utilizes InterQual® criteria and/or tools, which Harvard Pilgrim may have customized. You may request authorization and complete the automated authorization questionnaire via HPHConnect at www.harvardpilgrim.org/providerportal. In some cases, clinical documentation may be required to complete a medical necessity review. Please submit required documentation as follows:

• Clinical notes/written documentation —via HPHConnect Clinical Upload or secure fax (800-232-0816)

Providers may view and print the medical necessity criteria and questionnaire via HPHConnect for providers (Select Resources and the InterQual® link) or contact the commercial Provider Service Center at 800-708-4414. (To register for HPHConnect, follow the instructions here.) Members may access these materials by logging into their online account (visit www.harvardpilgrim.org, click on Member Login, then Plan Details, Prior Authorization for Care, and the link to clinical criteria) or by calling Member Services at 888-333-4742.

Policy and Coverage Criteria:

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

I. A General Reconstructive and Cosmetic Surgery

Coverage Guidelines

Reconstructive surgery and procedures are covered when the services are necessary to relieve pain or restore a bodily function that is impaired as a result of a congenital defect, birth abnormality, traumatic injury or covered surgical procedure. Prior authorization is required.

For Massachusetts products only, consistent with Chapter 233 of the Acts of 2016, reconstructive surgery and procedures to repair disturbances of body composition caused by HIV-associated lipodystrophy syndrome are covered when there is documentation from a treating provider that the treatment is necessary for correcting, repairing or ameliorating the effects of HIV-associated lipodystrophy syndrome1. Prior authorization is required.

In accordance with the federal Women's Health and Cancer Rights Act of 1998 (WHCRA)2 and applicable state regulations, breast reconstructive procedures 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

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HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members' unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g. Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

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.

Codes:

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-10CM Codes:

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

II. B. Redundant Skin – Surgical Removal (Panniculectomy)

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, also known as an abdominoplasty, 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.

Coverage Guidelines

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

• Skin necrosis, recalcitrant to conventional wound healing interventions such as debridement
• Recurrent skin infections requiring systemic antibiotics or systemic antifungals
  • Recurrent to be defined as at least two incidences in a 12-month period
• 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 the 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 bariatric surgery is performed, the weight loss has been maintained for at least six (6) months and no more than an additional twenty (20)

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pound weight loss is anticipated before the Member will be considered for a procedure based on the above criteria.

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:

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

The Plan will not cover brachioplasty, thighplasty, etc.

The Plan will not cover the surgical removal of redundant skin or body contouring for cosmetic purposes only.

Codes:

The following CPT codes require prior authorization

C. 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.

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 is met:

• Hemangioma is visible (above clothing) on the face, neck, or ears;
• Hemangioma compromises the function of vital structures, (e.g., vocal cord, auditory impairment); OR

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HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g. Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

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.

• 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.

Port Wine Stain Treatment

Port Wine Stain Treatment Tufts Health Plan considers laser treatment of a Port-Wine Stain (nevus flammeus) as medically necessary with a limit of 6 treatments when documentation confirms ANY of the following criteria:

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

Limitations:

• Additional treatments (beyond the initial six) will require authorization with documentation provided that supports the need for additional treatments based upon the original size of the hemangioma and the treatment response to date. Up to two (2) additional treatments may be authorized per request.
• The Plan will not authorize the coverage of invasive treatments for cutaneous congenital hemangiomas and port-wine stains for cosmetic reasons only, including relating to seasonal changes in appearance of the lesions.

Codes:

The following CPT codes require prior authorization

Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); less than 10 sq. cm - Code: 17106

Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); 10.0 to 50.0 sq. cm - Code: 17107

Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); over 50.0 sq. cm - Code: 17108

Coverage

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:

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 Gender Affirming Procedures Medical Necessity Guideline for more information.

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

Limitations

The Plan will not cover the removal of hair for cosmetic purposes. Cosmetic means to change or improve appearance. Hair removal may be covered with diagnosis of gender dysphoria

Codes:

• 17380 - Electrolysis epilation, each 30 minutes
• 17999 - Unlisted procedure, skin, mucous membrane and

• F64-F64.9 | Gender identity disorder
• 287.890 - Personal history of sex reassignment

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HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g. Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

Labiaplasty

Coverage Guidelines

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

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

Limitations

The Plan will not cover labiaplasty for cosmetic purposes

Codes

The following CPT code requires prior authorization

CPT Code: 56620

Description: Vulvectomy simple; partial

ICD-10 Code: N90.60

Description: Unspecified hypertrophy of vulva

ICD-10 Code: N90.61

Description: Childhood asymmetric labium majus enlargement

ICD-10 Code: N90.69

Description: Other specified hypertrophy of vulva

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F. Breast Reconstruction

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
2. 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 Description: Mastopexy
• CPT Code: 19340 Description: Insertion of breast implant on same day of mastectomy (ie, immediate)
• CPT Code: 19342 Description: Insertion or replacement of breast implant on separate day from mastectomy
• CPT Code: 19355 Description: Correction of inverted nipples
• CPT Code: 19361 Description: Breast reconstruction; with latissimus dorsi flap
• CPT Code: 19364 Description: Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap)
• CPT Code: 19367 Description: Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap
• CPT Code: 19369 Description: Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap

This policy utilizes InterQual® criteria and/or tools, which Harvard Pilgrim may have customized. You may request authorization and complete the automated authorization questionnaire via HPHConnect at www.harvardpilgrim.org/providerportal. In some cases, clinical documentation may be required to complete a medical necessity review. Please submit required documentation as follows:

• Clinical notes/written documentation —via HPHConnect Clinical Upload or secure fax (800-232-0816)

Providers may view and print the medical necessity criteria and questionnaire via HPHConnect for providers (Select Resources and the InterQual® link) or contact the commercial Provider Service Center at 800-708-4414. (To register for HPHConnect, follow the instructions here.)

Members may access these materials by logging into their online account (visit www.harvardpilgrim.org, click on Member Login, then Plan Details, Prior Authorization for Care, and the link to clinical criteria) or by calling Member Services at 888-333-4742.

Breast Implant Removal

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HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

Coverage

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

• upon the following InterQual criteria: ¢ Breast Implant Removal (Version 2023)

CPT Code Description

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

Gynecomastia: Surgical Correction by Mastectomy, Male For this The draws policy plan upon the following InterQual criteria

• CPT Code: 19300 - Mastectomy for gynecomastia
• e
• 19318 - Breast Reduction Reduction Mammoplasty, Male (Version 2023) e Reduction Mammoplasty, Male (Adolescent) (Version 2023) Reduction Mammoplasty for Symptomatic Macromastia, Female

For this policy, The Plan draws the upon following InterQual criteria:

• e Reduction Mammoplasty, Female (Version 2023) e Reduction Mammoplasty Female (Adolescent) (Version 2023)

Rhinoplasty Codes

For this policy, The Plan draws upon the following InterQual criteria:

• The following CPT codes require Prior Authorization
• CPT Code: 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

Description Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip Rhinoplasty, primary, complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip Rhinoplasty, primary; including major septal repair Rhinoplasty, secondary; minor revision (small amount of nasal tip work) Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)30420 304303043530450

Note: If rhinoplasty is being requested for the indication of gender reassignment, please refer to Medical Necessity Guidelines: Gender Affirming Medical Necessity Guidelines Note: For the diagnosis of cleft lip

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HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

• and/or cleft authorization:
• palate, the following CPT codes are covered without

CPT Code

Description

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

and/or cleft palate, the following CPT codes are covered without prior authorization:

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

Exclusions:

Harvard Pilgrim Health Care (HPHC) considers the following as cosmetic and therefore not medically necessary:

• Chemical Peel (dermal and epidermal)
• Dermabrasion
• Hair removal by any method, temporary or permanent, including, but not limited to, electrolysis, waxing,
• e 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)
• Microdermabrasion
• Removal of skin tags
• Removal of decorative tattoo
• Shaving or removal of a benign, asymptomatic epidermal or dermal lesions
• 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)