COSMETIC AND RECONSTRUCTIVE PROCEDURES

COSMETIC AND RECONSTRUCTIVE PROCEDURES CLINICAL POLICY Policy Number: SURGERY 035.21 T2 Effective Date: April 1, 2013 Table of Contents CONDITIONS OF COVERAGE... COVERAGE RATIONALE BENEFIT CONSIDERATIONS... BACKGROUND... APPLICABLE CODES... REFERENCES... POLICY HISTORY/REVISION INFORMATION... Policy History Revision Information Page 2 2 4 4 5 9 10 Related Policies: Blepharoplasty, Blepharoptosis and Brow Ptosis Repair Breast Reconstruction Post Mastectomy Breast Reduction Surgery Breast Repair/ Reconstruction (Not Following a Mastectomy) Gynecomastia In-Network Exceptions for Breast Reconstruction Surgery Following Mastectomy Omnibus Codes Orthognathic/Jaw Surgery Panniculectomy and Body Contouring Procedures Pectus Deformity Repair Plagiocephaly and Craniosynostosis Treatment Procedures for Ablation of Varicose Veins Rhinoplasty, Septoplasty, and Repair of Vestibular Stenosis The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern. 1

CONDITIONS OF COVERAGE Applicable Lines of Business/Products Benefit Type Referral Required (Does not apply to non-gatekeeper products) Authorization Required (Precertification always required for inpatient admission) Precertification with Medical Director Review Required Applicable Site(s) of Service (If site of service is not listed, Medical Director review is required) Special Considerations This policy applies to Oxford Commercial plan membership General benefits package No Yes 1 Yes 1 Inpatient, Outpatient, Office 1 Requests for all potentially cosmetic procedures must be pre-certified. To determine whether or not the procedures meet criteria as reconstructive and corrective, all such requests are subject to review by a Medical Director or their designee. COVERAGE RATIONALE I. Required Documentation: The decision regarding whether the requested procedure will be covered as a reconstructive and medically necessary will require review of the following clinical information/documentation, and such other documentation as may be reasonably requested: A. Contemporaneous physician office notes with the history of the medical condition(s) requiring treatment or surgical intervention. This documentation must include ALL of the following: i. A well-defined physical and/or physiological abnormality resulting in a medical condition that has required or requires treatment; AND ii. The physical and/or physiological abnormality has resulted in a functional deficit; AND iii. The functional deficit is recurrent or persistent in nature B. Appropriate clinical studies/tests addressing the physical and/or physiological abnormality that confirm its presence and the degree to which it is causing impairment C. High-quality color photographs, where applicable, documenting the physical and/or physiological abnormality accounting for the functional impairment (as defined in the Definitions section below). The date taken and the service reference number (obtained at the time of precertification) or the patients name and ID number must be documented on the photograph(s). D. Treating physician s plan of care (proposed procedures), which must include the expected outcome for the improvement of the functional deficit. II. Criteria for a Coverage Determination as Reconstructive: When complete, we will review the information supplied above to render a coverage determination. A requested procedure will be deemed reconstructive and therefore medically necessary when: 2

A. There has been documentation of a physical and/or physiological abnormality and quantification by contemporaneous office notes, objective studies and tests, and photographs, where applicable, of the physical and/or physiological abnormality B. There is documentation that the physical abnormality and/or physiological abnormality is causing a functional impairment (as defined in the Definitions section below) that requires correction C. The proposed treatment is of proven efficacy; and is deemed likely to significantly improve or restore the patient s physiological function Additional Information Definitions Abdominoplasty: typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty Blepharoplasty: a surgical procedure in which redundant tissue of skin, muscle or fat are excised from the upper or lower eyelid. Brow Ptosis: is a condition in which the eyebrow droops or sags. Breast Reduction Mammoplasty: includes reshaping the breast, gland resection and reposition of the nipple-areolar complex. The procedure is usually done under general anesthesia and may be performed in either an inpatient or outpatient setting. Cleft Lip & Palate: birth defects that affect the upper lip and roof of the mouth. They happen when the tissue that forms the roof of the mouth and upper lip don't join before birth. The problem can range from a small notch in the lip to a groove that runs into the roof of the mouth and nose. Congenital Anomaly: is a physical developmental defect that is present at the time of birth, and that is identified within the first twelve months of birth. Cosmetic Surgery: defined by the American Society of Plastic Surgeons, "is performed to reshape normal structures of the body in order to improve the patient's appearance and selfesteem." Functional/Physical Impairment: a physical/functional or physiological impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas: physical and motor tasks; independent movement; performing basic life functions. High Quality Photograph: ideally a high-quality print should be in color have at least 200 pixels per inch. It must be detailed enough to show the patient s anatomy that is described in the physician s office notes. If submitted as a hard copy, the image must be on photographic paper. Injury: bodily damage other than Sickness, including all related conditions and recurrent symptoms. Mastectomy: surgical removal of the breast. For the purposes of this policy, mastectomy includes the excision of a breast or of a lump. 3

Panniculectomy: involves the removal of hanging excess skin/fat in a transverse or vertical wedge but does not include muscle plication, neoumbilicoplasty or flap elevation. A cosmetic abdominoplasty is sometimes performed at the time of a functional panniculectomy. Panniculus: is a medical term describing a dense layer of fatty tissue growth, usually in the abdominal cavity. It can be a result of morbid obesity and can be mistaken for a tumor or hernia. Ptosis of Eyelids: drooping or sagging. Reconstructive Surgery: defined by the American Society of Plastic Surgeons, "is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Sickness: physical illness, disease or Pregnancy. The term Sickness as used in this Certificate does not include mental illness or substance abuse, regardless of the cause or origin of the mental illness or substance abuse. Visual Field: the total area where objects can be seen in the peripheral vision while the eye is focused on a central point. BENEFIT CONSIDERATIONS Requests for all potentially cosmetic procedures must be pre-certified. To determine whether or not the procedures meet criteria as reconstructive and corrective, all such requests are subject to medical director review. Requests for potentially cosmetic surgery will be certified as reconstructive, and therefore covered, only when: The surgery is performed because of congenital disease or an anomaly of a covered dependent child, which has resulted in a functional defect*; OR The surgery is incidental to or follows surgery resulting from trauma, infection or disease of the involved part, OR There are medical complications occurring as a result of an initial injury, and the surgery can reasonably be expected to improve or restore bodily function. * Refer to definition for functional/physical impairment. Surgical procedures may also be considered reconstructive if they are required for the prompt (i.e., as soon as medically feasible) repair of accidental injury. Surgery is not considered reconstructive and corrective when performed to correct a variant of a normal condition. (e.g., protruding ears, or diastasis recti, ICD-9 728.84, 665.8); or when performed solely to improve appearance or self image when there is no associated functional deficit (such as a scar perceived as unattractive following an operation on the gallbladder or colon). In these types of cases, the surgery would be deemed cosmetic and, therefore, not covered. Examples: a. Treatment of severe burns or repair of the face following a serious automobile accident would be covered as reconstructive surgery. b. A torn earlobe would be covered for prompt repair; however, it would not be covered at a later date for either repair (because repair was not prompt), or revision (because the indication is entirely cosmetic, with no improvement of function). 4

BACKGROUND Reconstructive and Corrective surgery is performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. The surgery is generally performed to improve function. Cosmetic Surgery, as defined by the American Society of Plastic and Reconstructive Surgeons, "is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem." Cosmetic surgery is excluded from coverage by the Member's certificate of insurance, and is not a covered benefit. However, Oxford does cover reconstructive surgery. The accompanying list of CPT codes includes many (although not all) of the services that are frequently cosmetic in nature. If a service represented by a CPT code or codes on this list (See Payment Guidelines) or otherwise identified as a cosmetic procedure is requested, it is subject to Medical Director Review. If the service requested does not meet criteria established under the Cosmetic and Reconstructive Procedures policy, or under other specific policies dealing with reconstructive or medically necessary services, the request will be non-certified as "medical criteria APPLICABLE CODES The codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the Member s plan of benefits or Certificate of Coverage. This list of codes may not be all inclusive. CPT Procedure Code Blepharoplasty, blepharoptosis, brow ptosis repair, canthopexy and other eye procedures CPT code section. Please see Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair policy for codes and coverage criteria. Codes below are not in the blepharoplasty and brow ptosis policy. 21280 Medial canthopexy (separate procedure) 21282 Lateral canthopexy Correction of lagophthalmos, with implantation of upper eyelid lid load 67912 (eg, gold weight) Breast reconstruction post mastectomy CPT code section- please see breast reconstruction post mastectomy policy for codes and coverage criteria Mastopexy 19316 (This code is Cosmetic except when used post-mastectomy; see Breast Reconstruction Post Mastectomy) Breast reduction surgery CPT code section - please see Breast Reduction Surgery policy for coverage criteria Breast repair/reconstruction not following mastectomy CPT code section - please see Breast Repair/Reconstruction Not Following Mastectomy policy. Craniofacial procedures CPT code section 21137 Reduction forehead; contouring only Reduction forehead; contouring and application of prosthetic material 21138 or bone graft (includes obtaining autograft) Reduction forehead; contouring and setback of anterior frontal sinus 21139 wall Reconstruction superior-lateral orbital rim and lower forehead, 21172 advancement or alteration, with or without grafts (includes obtaining autografts) Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, 21175 trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts) 5

CPT Procedure Code 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) 21181 Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranial Reconstruction of orbital walls, rims, forehead, nasoethmoid complex 21182 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 21183 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 21184 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 21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 21209 Osteoplasty, facial bones; reduction 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) 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 21270 Malar augmentation, prosthetic material 21275 Secondary revision of orbitocraniofacial reconstruction 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 21299 Unlisted craniofacial and maxillofacial procedure Dental procedures CPT code section 21248 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial 21249 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete Filler Material SQ Injections: Q2026 Injection Radiesse 0.1ML is covered when used for treatment of facial defects due to facial lipidatrophy in persons with human immunodeficiency virus (HIV) and treatment of vocal fold insufficiency; Q2027 Injection Sculptra 0.1ML is covered when used for treatment of facial defects due to 6

CPT Procedure Code facial lipidatrophy in persons with human immunodeficiency virus (HIV) Other uses of these devices may be cosmetic. Also see Omnibus Codes Policy 11950 Subcutaneous injection of filling material (eg, collagen); 1 cc or less 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 Flap Procedures CPT Code Section: The code 15732 is not appropriate for use for face lifts. The following is based on AMA CPT coding guidance: Coding Tips 15732 Muscle, myocutaneous, or fasciocutaneous flap; head and neck (eg, temporalis, masseter muscle, sternocleidomastoid, levator scapulae) Reporting of a muscle, myocutaneous, or fasciocutaneous flap differs from that of other flaps as the procedure is always identified by the donor site when a tube is formed for later transfer or when a flap "delay" occurs prior to transfer but never by the recipient site. Extensive immobilization and/or repair of the donor site is reported separately. When 15732 is performed with another separately identifiable procedure, the highest dollar value code is listed as the primary procedure and subsequent procedures are appended with modifier 51. If significant additional time and effort is documented, append modifier 22 and submit a cover letter and operative report. Section Notes - 15570-15738 Wound Reconstruction: Skin Flaps - (15570-15738) Wound Reconstruction: Skin Flaps Includes: - Ankle or wrist if code description describes leg or arm - Code based on recipient site - Fixation and anchoring skin graft - Routine dressing - Simple tissue debridement - Tube formation for later transfer Excludes: Debridement without immediate primary closure (11042-11047 [11045, 11046], 97597-97598) Excision of: - Benign lesion (11400-11471) - Burn eschar or scar (15002-15005) - Malignant lesion (11600-11646) - Microvascular repair (15756-15758) Primary procedure such as radical mastectomy, extensive tumor removal, orbitectomy (see appropriate anatomical site) Code also application of extensive immobilization apparatus Code also repair of donor site with skin grafts or flaps 15732 Muscle, myocutaneous, or fasciocutaneous flap; head and neck (eg, temporalis, masseter muscle, sternocleidomastoid, levator scapulae) 15734 Muscle, myocutaneous, or fasciocutaneous flap; trunk 15736 Muscle, myocutaneous, or fasciocutaneous flap; upper extremity 15738 Muscle, myocutaneous, or fasciocutaneous flap; lower extremity Gynecomastia CPT code section - please see Gynecomastia policy for codes and 7

CPT Procedure Code coverage criteria Orthognathic/jaw surgery CPT code section - please see Orthognathic/Jaw Surgery policy for codes and coverage criteria. The codes below are not in the Orthognathic/Jaw Surgery policy. Reconstruction of zygomatic arch and glenoid fossa with bone and 21255 cartilage (includes obtaining autografts) 21299 Unlisted craniofacial and maxillofacial procedure Panniculectomy and body contouring procedures CPT code section - please see Panniculectomy and Body Contouring Procedures for codes and coverage criteria Pectus excavatum reconstructive repair procedures CPT code section - please see Pectus Deformity Repair policy 21740 Reconstructive repair of pectus excavatum or carinatum; open Reconstructive repair of pectus excavatum or carinatum; minimally 21742 21743 invasive approach (nuss procedure), without thoracoscopy Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (nuss procedure), with thoracoscopy Rhinoplasty, septoplasty, repair of vestibular stenosis, and turbinate resection and nose procedures CPT code section - please see Rhinoplasty, Septoplasty and Repair of Vestibular Stenosis for codes and coverage criteria. The codes below are not in the Rhinoplasty, Septoplasty, and Repair of Vestibular Stenosis policy. 30120 Excision or surgical planing of skin of nose for rhinophyma 30540 Repair choanal atresia; intranasal 30545 Repair choanal atresia; transpalatine 30560 Lysis intranasal synechia 30620 Septal or other intranasal dermatoplasty (does not include obtaining graft) Veins CPT code section - please see Procedures for Ablation of Varicose Veins policy for codes and coverage criteria. The codes below are not in the Procedures for Ablation of Varicose Veins policy. The following spider vein codes are considered cosmetic; the codes do not improve a functional physical or physiological impairment. 36468 36469 Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); face Miscellaneous - Cosmetic And Reconstructive Procedures CPT Code Section The following codes are considered cosmetic; the codes do not improve a functional, physical or physiological impairment. 11960 Insertion of tissue expander(s) for other than breast, including subsequent expansion 15775 Punch graft for hair transplant; 1 to 15 punch grafts 15776 Punch graft for hair transplant; more than 15 punch grafts 15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis 15781 Dermabrasion; segmental, face 15782 Dermabrasion; regional, other than face 15783 Dermabrasion; superficial, any site (eg, tattoo removal) 15786 Abrasion; single lesion (eg, keratosis, scar) 15787 Abrasion; each additional 4 lesions or less (list separately in addition to code for primary procedure) 15788 Chemical peel, facial; epidermal 15789 Chemical peel, facial; dermal 15792 Chemical peel, nonfacial; epidermal 15793 Chemical peel, nonfacial; dermal 15819 Cervicoplasty 15824 Rhytidectomy; forehead 8

CPT Procedure Code 15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, p-flap) 15826 Rhytidectomy; glabellar frown lines 15828 Rhytidectomy; cheek, chin, and neck 15829 Rhytidectomy; superficial musculoaponeurotic system (smas) flap 17380 Electrolysis epilation, each 30 minutes 17999 Unlisted procedure, skin, mucous membrane and subcutaneous tissue 19325 Mammaplasty, augmentation; with prosthetic implant 28344 Reconstruction, toe(s); polydactyly 40500 Vermilionectomy (lip shave), with mucosal advancement 69090 Ear piercing 69300 Otoplasty, protruding ear, with or without size reduction 69320 Reconstruction external auditory canal for congenital atresia, single stage HCPCS Procedure Code L8600 S2066 S2067 S2068 Implantable breast prosthesis, silicone or equal Breast reconstruction with gluteal artery perforator (gap) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral Breast reconstruction of a single breast with "stacked" deep inferior epigastric perforator (diep) flap(s) and/or gluteal artery perforator (gap) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateral Breast reconstruction with deep inferior epigastric perforator (diep) flap or superficial inferior epigastric artery (siea) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral REFERENCES The foregoing Oxford policy has been adapted from an existing UnitedHealthcare national policy that was researched, developed and approved by UnitedHealthcare Medical Technology Assessment Committee. [CR-001] 1. American Medical Association. Current Procedural Terminology: CPT Professional Edition. AMA press. 2. Oxford Certificate of Coverage and Member Handbook. 3. American Society of Plastic Surgeons (ASPS) available @: http://www.plasticsurgery.org 4. Official Compilation of Codes, Rules and Regulations of the State of New York Title 11 Insurance Dept., Chapter III Policy and Certificate Provisions Section 52.16, c(5). 5. New Jersey Administrative Code, Title 11,Chapter 4, Subchapter 16, Minimum standards for Individual Health Insurance; 11:4-16.5(5). POLICY HISTORY/REVISION INFORMATION Date 04/01/2013 Action/ Added reference links to policies titled: o Omnibus Codes o Pectus Deformity Repair 9

o Plagiocephaly and Craniosynostosis Treatment Removed reference link to policy titled Muscle, Myocutaneous and Fasciocutaneous Flaps Reformatted and revised list of applicable procedure codes: o Craniofacial Procedures: Added 21208, 21209, 21296 and 21299 o Dental Procedures: Added 21248 and 21249 o Flap Procedures: Added 15732 (not appropriate for use for face lifts), 15734, 15736 and 15738 o Filler Material SQ Injections: Added coding clarification language to indicate: Q2026 (Injection Radiesse 0.1ML) is covered when used for treatment of facial defects due to facial lipidatrophy in persons with human immunodeficiency virus (HIV) and treatment of vocal fold insufficiency Q2027 (Injection Sculptra 0.1ML) is covered when used for treatment of facial defects due to facial lipidatrophy in persons with human immunodeficiency virus (HIV); other uses of these devices may be cosmetic o Orthognathic/Jaw Surgery: Added 21255 o Pectus Excavatum Reconstructive Repair: Added 21740, 21742 and 21743 o Veins: Removed 37735 o Miscellaneous Cosmetic and Reconstructive Procedures: Added 11960, 17999, 28344, 40500, 69320, L8600 S2066, S2067 and S2068 Archived previous policy version SURGERY 035.20 T2 10