Reconstructive and Cosmetic Health Services
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Defines medical necessity criteria and coverage stance for reconstructive versus cosmetic surgical and nonsurgical services for Aspirus Health Plan members; applies to providers requesting coverage determinations and prior authorization for reconstructive services.
No material clinical or coverage changes in this revision.
Coverage Criteria: Reconstructive vs Cosmetic Services
Reconstructive services (medical necessity)
Medically necessary when ALL of the following are met:
From policy 'RECONSTRUCTIVE SERVICES'
criterion 1
criterion 2
criterion 3
criterion 4
criterion 5
Cosmetic services are NOT MEDICALLY NECESSARY. Procedures performed primarily to improve appearance rather than to restore function or correct a deformity are excluded from coverage under this policy.
Examples of procedures considered cosmetic and not medically necessary include, but are not limited to: abdominoplasty or panniculectomy performed primarily to improve appearance; adipose tissue replacement by insertion or injection of prosthetic material; breast augmentation of otherwise normal breasts; breast implant removal or revision for non‑medical reasons; breast inverted nipple correction; and breast lift (mastopexy) for sagging breasts.
Additional cosmetic procedures include diastasis recti repair for appearance only; ear piercing and earlobe repair to close a stretched pierce hole; excess skin excision from thigh, leg, hip, buttock, arm, forearm, hand, submental fat pad, neck, or other areas performed primarily for appearance; facial contouring such as chin or cheek implants for external deformities not due to trauma or disease; and facial rejuvenation procedures (e.g., rhytidectomy/face lift, eyelid lift, neck lift, brow lift, glabellar line correction, and injection of filling materials including collagen or fat for cosmetic effect).
Also excluded are hair removal or replacement; lipectomy/liposuction; medical aesthetic treatments (e.g., dermabrasion, chemical exfoliation, cryotherapy, laser resurfacing) when performed for photo‑aging, pigmentary changes, acne scarring, or telangiectasias from rosacea; otoplasty for prominent ears without functional deficit; penile enlargement (phalloplasty); rhinoplasty performed solely for appearance; sclerosing of spider veins; septoplasty performed solely for cosmetic reasons; skin lesion removal done solely for cosmetic purposes; procedures to treat psychiatric or emotional distress; tattoo removal; treatment of non–port‑wine stain vascular lesions performed primarily to alter appearance; and vaccination scar repair/revision.
Full enumeration of procedures performed primarily to improve appearance (not medically necessary) includes the following items as listed in the policy:
1. Abdominoplasty or panniculectomy performed primarily to improve appearance; 2. Adipose tissue replacement by insertion or injection of prosthetic material; 3. Breast augmentation (augmentation mammoplasty) of small but otherwise normal breasts; 4. Breast implant removal or revision for non‑medical reasons; 5. Breast inverted nipple correction; 6. Breast lift (mastopexy) to treat sagging of the breast; 7. Diastasis recti repair (for appearance); 8. Ear piercing and earlobe repair to close a stretched pierce hole; 9. Excess skin excision from thigh, leg, hip, buttock, arm, forearm or hand, submental fat pad (double chin), neck, or other areas; 10. Facial contouring (chin implant or cheek enhancement) for external deformities not due to trauma or disease; 11. Facial rejuvenation procedures (e.g., rhytidectomy, eyelid lift, neck lift, brow lift, excision/correction of glabellar frown lines, injection of filling material including collagen or fat); 12. Flesh‑color tattooing and cosmetics for port‑wine stains, hemangiomas, or birthmarks (cosmetic applications); 13. Hair removal or replacement by any means; 14. Lipectomy removal of fatty tissue (e.g., suction‑assisted liposuction, lipoplasty); 15. Medical aesthetic treatments (dermabrasion, chemical exfoliation, cryotherapy, liquid nitrogen, dry ice, CO2 snow, laser resurfacing) for photo‑aged skin, dyschromias/pigmentations, acne scarring, or telangiectasias from rosacea; 16. 'Moon Face' surgery to correct cortisone therapy side effects; 17. Otoplasty (ear pinning) for lop, bat, or prominent ears without functional deficiency; 18. Penis enlargement (phalloplasty); 19. Rhinoplasty unless performed to improve a documented functional impairment that cannot be addressed with septoplasty alone; 20. Sclerosing of spider veins and/or telangiectasis; 21. Septoplasty performed solely to improve appearance without signs or symptoms of functional respiratory abnormality; 22. Skin lesion removal when done solely for cosmetic purposes; 23. Surgery performed to treat psychiatric or emotional distress; 24. Tattoo removal including excision and salabrasion of decorative tattoos; 25. Treatment of non–port‑wine stain hemangiomas and other vascular abnormalities performed primarily to alter or enhance cosmetic appearance (e.g., spider veins, cherry angiomas, facial telangiectasias, strawberry hemangiomas); 26. Vaccination scar repair/revision.
Provider Actions, Authorizations, and Documentation
Prior authorization required for listed reconstructive services
Prior authorization is required for reconstructive services listed on the Aspirus authorizations webpage. Providers may submit clinical information before the procedure using the Aspirus Health Plan prior authorization form or the Medicare Pre-Determination Request; links and forms are available on the Aspirus authorizations page.
Topical therapy trial required before dermabrasion
For dermabrasion of multiple superficial lesions, the policy requires that a trial of topical 5‑fluorouracil (Efudex) or imiquimod (Aldara) has failed or is contraindicated before proceeding with dermabrasion when conventional removal methods are impractical due to number/distribution of lesions.
- Applies when cryotherapy, curettage, and excision are impractical because of lesion number or distribution.
- Document prior topical therapy trial and reason for failure or contraindication.
Required clinical documentation to substantiate functional improvement
Medical documentation submitted must substantiate how the proposed surgery will improve function; examples provided by the policy should be included with the request.
- Operative reports
- Photographs
- Specialty consultations
- Diagnostic imaging
Risk of post‑procedure review and denial if no prior authorization
Procedures that require prior authorization but are performed without prior authorization may be reviewed after the procedure and potentially denied if medical necessity is not substantiated.
- Submitting clinical information prior to the procedure using the prior authorization form is optional but recommended to avoid post-procedure denials.
Definitions
Background
Reconstructive services are intended primarily to restore function or to correct deformities resulting from disease, injury, trauma, prior surgery, or congenital malformations and must be likely to significantly improve the functional ability of the involved body part.
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