Sunflower Health Plan Cosmetic and Reconstructive Procedures (PDF) Form

This policy will provide general guidelines as to when cosmetic and reconstructive surgery is or is not medically necessary. Not all cosmetic procedures are listed in this policy. The Medical Director has the final decision to deny coverage for services deemed cosmetic in nature and not medically necessary. Policy/Criteria I. It is the policy of health plans affiliated with Centene Corporation® that reconstructive procedures are considered medically necessary when meeting all of the following: A. Intent of the procedure meets one of the following: 1. The procedure is performed to improve the function of an abnormal body part caused by illness, trauma, or a congenital defect after failure of conservative therapy (unless conservative therapy is not standard of care for the condition, or is contraindicated); 2. Skin tag removal when located in an area of friction with documentation of repeated irritation and bleeding (refer to Benefit Plan Contract for any coverage restrictions); 3. Scar/keloid revision/removal when accompanied by pain unresponsive to standard therapy and is recurrently infected, unstable, friable; or with functional impairment; 4. Certain reconstructive procedures may be covered if improving appearance is the only benefit, e.g. post-mastectomy breast reconstruction. These procedures may include, but are not limited to: a. Post-mastectomy*, medically necessary lumpectomy, or other medically necessary breast surgery resulting in asymmetry: breast reconstruction, including nipple reconstruction, tattooing and surgery on contralateral breast to restore symmetry; b. Use of FDA-approved facial dermal injections [Poly-L-Lactic acid (Sculptra™), calcium hydroxylapatite microspheres (Radiesse®)] or autologous fat transfers for HIV-associated wasting** when meeting both of the following: i. Diagnosis of HIV (human immunodeficiency virus) or AIDS (acquired immunodeficiency syndrome); ii. Diagnosis of facial lipodystrophy syndrome (LDS); Note: Please refer to CP.MP.95 Gender Affirming procedures for procedures related to treatment of gender dysphoria. B. Medical records with photographs are provided, as applicable. Refer to the most current version of the Health Plan adopted nationally recognized decision support tools for other procedures that may be considered cosmetic in certain cases. Page 1 of 12 CLINICAL POLICY Cosmetic and Reconstructive Procedures *Note: This includes reconstruction after prophylactic mastectomy with BRCA mutation if the mastectomy is a covered benefit in the State. **Note: For Serostim (somatropin) for HIV associated wasting, see CP.PHAR.517 Human Growth Hormone (Somapacitan, Somatrogon, Somatropin), Medicaid; CP.CPA.353 Human Growth Hormone (Somapacitan, Somatrogon, Somatropin), Commercial; or HIM.PA.161 Human Growth Hormone (Somapacitan, Somatrogon, Somatropin), Health Insurance Marketplace. For Egrifta (tesamorelin) for lipodystrophy, see CP.PHAR.109 Tesamorelin. II. It is the policy of Health Plans affiliated with Centene Corporation that cosmetic surgery is not medically necessary and generally not a covered benefit when performed to improve a patient’s normal appearance and self-esteem. These procedures include, but are not limited to: A. Excision of excessive skin B. Body contouring C. Body lift D. Breast augmentation E. Liposuction, excluding lipoma as directed by clinical decision support criteria F. Surgery to correct unsatisfactory results from previous cosmetic and/or non-covered service G. Revision, removal, or replacement of breast implants previously placed for cosmetic reasons H. Removal of excess skin or body contouring procedures following weight loss or bariatric surgery when removal is solely cosmetic I. Facial augmentation J. Abdominoplasty K. Dermabrasion L. Skin rejuvenation and resurfacing M. Electrolysis, laser hair removal N. Hair transplantation, when not performed to correct permanent hair loss caused by disease or injury O. Tattooing (except when covered for breast reconstruction post-mastectomy) P. Injectable filler Q. Circumcision revisions done only to improve appearance R. Mastopexy (except for breast reconstruction post-mastectomy, medically necessary lumpectomy, or other medically necessary breast surgery resulting in significant asymmetry) S. Correction of inverted nipples T. Repair of diastasis recti U. Breast reconstruction for fibroadenomas or other benign lesions, unless medically necessary per clinical decision support criteria. Page 2 of 12 CLINICAL POLICY Cosmetic and Reconstructive Procedures Background Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, previous or concurrent surgeries, trauma, infection, tumors or disease. It is generally performed to improve the functioning of a body part and may or may not restore a normal appearance.2 Functional impairment is a health condition in which the normal function of a part of the body or organ system is less than age appropriate at full capacity, such as decreased range of motion, diminished eyesight or hearing, etc. that variably impacts activities of daily living.3 Cosmetic surgery is performed to reshape normal structures of the body in order to improve the appearance and self-esteem of a patient. It is generally not considered medically necessary.1 Coding Implications This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2022, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. CPT Codes That Support Coverage Criteria CPT Codes Codes 11200 11201 11400 11401 11402 11403 11404 11406 11420 11421 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof (List separately in addition to code for primary procedure) 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 Page 3 of 12 CLINICAL POLICY Cosmetic and Reconstructive Procedures CPT Codes Codes 11422 11423 11424 11426 11440 11441 11442 11443 11444 11446 11920 11921 11922 15773 15774 15788 15789 15792 15793 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm 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 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 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 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 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 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 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm 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) Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure) Chemical peel, facial; epidermal Chemical peel, facial; dermal Chemical peel, nonfacial; epidermal Chemical peel, nonfacial; dermal Page 4 of 12 CLINICAL POLICY Cosmetic and Reconstructive Procedures CPT Codes Codes 15830 15832 15833 15834 15835 15836 15837 15220 15221 15771 15772 15775 15776 15838 15839 15847 15876 15877 15878 15879 15792 15793 17110 17111 19301 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure) Punch graft for hair transplant; 1 to 15 punch grafts Punch graft for hair transplant; more than 15 punch grafts Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area 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) Suction assisted lipectomy; head and neck Suction assisted lipectomy; trunk Suction assisted lipectomy; upper extremity Suction assisted lipectomy; lower extremity Chemical peel, nonfacial; epidermal Chemical peel, nonfacial; dermal 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 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 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); Page 5 of 12 CLINICAL POLICY Cosmetic and Reconstructive Procedures CPT Codes Codes 19302 19303 19316 19318 19325 19328 19330 19340 19342 19350 19355 19357 19361 19364 19367 19368 19369 19370 19371 19380 19396 19499 21120 21121 21122 21123 21137 21138 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy Mastectomy, simple, complete Mastopexy Breast reduction Breast augmentation with implant Removal of intact breast implant Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel) Insertion of breast implant on same day of mastectomy (ie, immediate) Insertion or replacement of breast implant on separate day from mastectomy Nipple/areola reconstruction Correction of inverted nipples Tissue expander placement in breast reconstruction, including subsequent expansion(s) Breast reconstruction; with latissimus dorsi flap Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap) Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging) Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents Revision of reconstructed breast (eg, significant removal of tissue, re- advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant- based reconstruction) Preparation of moulage for custom breast implant Unlisted procedure, breast Genioplasty; augmentation (autograft, allograft, prosthetic material) Genioplasty; sliding osteotomy, single piece Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin) Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) Reduction forehead; contouring only Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) Page 6 of 12 CLINICAL POLICY Cosmetic and Reconstructive Procedures CPT Codes Codes 21139 21159 21160 21172 21175 21179 21180 21181 21182 21183 21184 21230 21235 21255 21256 21260 21261 Reduction forehead; contouring and setback of anterior frontal sinus wall Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts) Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg,plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts) Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material) Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts) Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranial Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting less than 40 sq cm Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 40 sq cm but less than 80 sq cm Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 80 sq cm Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia) Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and extracranial approach Page 7 of 12 CLINICAL POLICY Cosmetic and Reconstructive Procedures CPT Codes Codes 21263 21267 21268 21270 21275 21280 21282 21295 21296 61550 61552 61556 61557 61558 61559 HCPCS Codes G0429 Q2026 Q2028 Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and extracranial approach Malar augmentation, prosthetic material Secondary revision of orbitocraniofacial reconstruction Medial canthopexy (separate procedure) Lateral canthopexy Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approach Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach Craniectomy for craniosynostosis; single cranial suture Craniectomy for craniosynostosis; multiple cranial sutures Craniotomy for craniosynostosis; frontal or parietal bone flap Craniotomy for craniosynostosis; bifrontal bone flap Extensive craniectomy for multiple cranial suture craniosynostosis (eg, cloverleaf skull); not requiring bone grafts Extensive craniectomy for multiple cranial suture craniosynostosis (eg, cloverleaf skull); recontouring with multiple osteotomies and bone autografts (e.g., barrel-stave procedure) (includes obtaining grafts) Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) as a result of highly active antiretroviral therapy) Injection, Radiesse, 0.1 ml Injection, Sculptra, 0.5 mg Reviews, Revisions, and Approvals Original creation Template updated. References reviewed. Criteria for panniculectomy removed and placed into CP.MP.109. References reviewed and updated References reviewed and updated Minor reorganization to section I. without content change. Revision Date 03/09 04/16 Approval Date 03/09 04/16 4/17 03/18 04/18 04/17 03/18 Page 8 of 12 CLINICAL POLICY Cosmetic and Reconstructive Procedures Reviews, Revisions, and Approvals Reorganized section 1 for clarity. Removed requirement that scar and keloid revisions must be in members under 18 years. Moved statement regarding documentation of medical records, photos. Removed specific mention of documentation of conservative therapies in the medical records criteria. Reorganized description and background sections. Removed “significant” in I.A.4.a. In II. N. changed “hair replacement” to “hair transplantation.” Added additional not medically necessary indications i.e., (mastopexy except for breast reconstruction post- mastectomy or lumpectomy resulting in significant asymmetry, correction of inverted nipples, and repair of diastasis recti. Specialist reviewed. References reviewed and updated. Added criteria for dermal injections and autologous fat injections for HIV-associated FLS. Changed policy title and medical necessity statements to state “cosmetic procedures” or “reconstructive procedures” instead of “cosmetic surgery” or “reconstructive surgery.” Added CPT and HCPCS codes for specified medically necessary indications. Added note to refer to CP.MP.95 Gender Affirming procedures for procedures related to treatment of gender dysphoria Clarified in II.N. that hair transplant is not medically necessary, when not performed to correct permanent hair loss caused by disease or injury. Added the following applicable CPT codes: 15220,15221, 15775, 15776. Supporting references added. Added applicable CPT codes: 15771, 15772. Annual review. Reviewed and updated references. CPT code description revised in 2021: 19318, 19325, 19328, 19340, 19342, 19357, 19361 19364, 19367, 19368, 19369, 19370, 19371, and 19380. CPT 19324 and 19366 deleted in 2021. Clarified in I.A.1. failure of conservative therapy “(unless conservative therapy is not standard of care for the condition, or is contraindicated).” Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” Added the following codes from the retired Craniofacial Surgery policy; 21120, 21121, 21122, 21123, 21137, 21138, 21139, 21159, 21160, 21172, 21175, 21179, 21180, 21181, 21182, 21183, 21184, 21230, 21235, 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21270, 21275, 21280, 21282, 21295, 21296, and craniectomy/craniotomy codes for craniosynostosis. Clarified in I.A.4.a. “Post-mastectomy,* medically necessary lumpectomy, or other medically necessary breast surgery.” Updated II.R. “Mastopexy (except for breast reconstruction post-mastectomy, medically necessary lumpectomy, other medically necessary breast surgery resulting in significant asymmetry). In II.E., changed “InterQual” to “Decision Support Criteria.” Added II.U. “Breast reconstruction for fibroadenomas or other benign lesions, unless medically necessary per clinical decision support criteria” to not Revision Date 03/19 Approval Date 03/19 02/20 03/20 04/20 05/20 09/20 09/20 01/21 03/21 03/21 08/21 08/21 10/21 10/21 Page 9 of 12 CLINICAL POLICY Cosmetic and Reconstructive Procedures Reviews, Revisions, and Approvals medically necessary procedures. Added codes 19330 and 19499. Annual review. References reviewed, updated, and reformatted. Annual review completed. Added to I.A.4.b. “poly-L-lactic acid” and “calcium hydroxylapatite microspheres”. Minor rewording with no clinical significance. References reviewed and updated. Reviewed by external specialist. Annual review. Minor edits to I.A.4.b with no clinical significance. Updated pharmacy policies for Serostim (somatropin) in note. Removed CPT code 11310. References reviewed and updated. Reviewed by internal specialist. Revision Date Approval Date 10/22 10/22 10/23 10/23