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    v1.0.30
    OpenPayerPolicy UpdatesPlastic/Reconstructive SurgeryDHA Lipedema Lipectomy Coverage Update | OpenPayer
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    ModifiedDHAPolicy 6010.60-M

    Cosmetic, Reconstructive, and Plastic Surgery — General Guidelines

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    General guidelines for cosmetic, reconstructive, and plastic surgery services under the TRICARE surgery benefit.

    Policy Summary
    PayerDHA
    PolicyCosmetic, Reconstructive, and Plastic Surgery — General Guidelines
    Policy CodePolicy 6010.60-M
    Change TypeModified
    Effective DateMay 28, 2021
    Next Review DateN/A
    Key ActionObtain prior authorization for lipectomy (liposuction) performed to treat lipedema.
    SourceLink
    POLICY UPDATE CHANGES

    Revision 136 added coverage criteria for lipectomy (liposuction) used to treat lipedema, effective May 28, 2021.

    Revision 136 modified the policy's effective-date section on November 6, 2024.

    7Covered circumstances
    <30Lipedema BMI requirement
    6 monthsConservative treatment requirement
    23Exclusion categories

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    5Excluded rhytidectomy codes

    Covered and Excluded Services

    Covered circumstances

    Benefits are allowed when the procedure meets at least one of the following covered circumstances.

    • Congenital anomaly: The procedure corrects a congenital anomaly.
    • Accidental injury: The procedure restores body form, including revision of scars, following an accidental injury.
    • Neoplastic-surgery scars: The procedure revises disfiguring and extensive scars resulting from neoplastic surgery.
    • Post-mastectomy reconstruction: The procedure is post-mastectomy breast reconstruction following a medically necessary mastectomy.

      See the related post-mastectomy reconstruction section.

    • Pectus excavatum: The procedure corrects pectus excavatum when the defect is more than a minor anatomical anomaly.More than a minor anatomical anomaly

      Covered as correction of a congenital anomaly.

    • Functionally necessary liposuction: Liposuction is used as a substitute for the scalpel and is medically necessary, appropriate, and the standard of care.Medically necessary, appropriate, and standard of care
    • Functionally necessary panniculectomy: Panniculectomy is performed in conjunction with other abdominal or pelvic surgery, and medical review determines that it significantly contributes to the safe and effective correction or improvement of a bodily function.Significant contribution to safe and effective functional improvement

      An example is improvement of skin integrity.

    Lipedema lipectomy

    Lipedectomy (liposuction) for lipedema may be covered only when all of the following conditions are met.

    Lipedema lipectomy criteria

    • Diagnosis and stage: The patient has a clinical diagnosis of lipedema stage I, II, or III.Stage I, II, or III
    • Age: The patient is aged 18 years or older.18 years or older
    • BMI: The patient's BMI is less than 30.BMI < 30

    Other medically necessary surgery

    Other surgeries may be covered when medical review determines that the surgery is medically necessary and integral to restoration of an individual bodily function.

    Medical necessity and functional restoration: The surgery is medically necessary and integral to restoration of an individual bodily function.Medical necessity and functional restoration

    The policy gives panniculectomy for chronic skin ulceration as an example.

    Timing of reconstruction after injury or trauma

    Procedures related to accidental injury or surgical trauma are subject to the following timing rule and exceptions.

    Timing exceptions

    • Standard timing: The procedure occurs by December 31 of the year following the injury or surgical trauma.By December 31 of the following year
    • Post-mastectomy exception: The procedure is authorized post-mastectomy reconstructive breast surgery.No time limitation between mastectomy and reconstruction
    • Pediatric growth exception: The case involves a child who may require a growth period.Special consideration

    The policy excludes dental congenital anomalies, including absent tooth buds and malocclusion. It also excludes procedures performed primarily for psychological or psychiatric reasons, as a result of aging, for elective correction of minor dermatological blemishes or marks, or for minor anatomical anomalies.

    Reduction mammoplasty is excluded unless medical documentation establishes intractable pain resulting from large pendulous breasts and confirms that the pain is not amenable to other forms of treatment.

    Rhytidectomy is excluded, including CPT codes 15824–15826, 15828, and 15829, except when performed to treat facial palsy, significant facial burns, or other significant major facial trauma.

    Procedures primarily intended to improve appearance, address psychological or psychiatric concerns, treat the aging process, correct minor blemishes or anatomical anomalies, improve a normal and acceptable feature, or perform body sculpting without a medically necessary functional purpose are not medically necessary under this policy. Related services, supplies, and institutional costs are also excluded when the underlying procedure does not qualify for benefits.

    Coding and Eligibility Parameters

    Excluded rhytidectomy CPT codesCPTNot Covered
    15824Rhytidectomy
    15825Rhytidectomy
    15826Rhytidectomy
    15828Rhytidectomy
    15829Rhytidectomy
    Lipedema stage
    Eligible stagesStage I, II, or III
    Required diagnosisClinical diagnosis of lipedema
    Covered serviceLipectomy (liposuction) for treatment of lipedema may be covered when all conditions are met
    Minimum age for lipedema lipectomy
    Minimum age18 years or older
    Applies toLipectomy (liposuction) for treatment of lipedema
    Requirement typeAll specified lipedema coverage conditions must be met

    Authorization, Documentation, and Denial Risks

    Prior Authorization

    Prior Authorization Required for Lipedema Lipectomy

    Prior authorization is required before lipedema lipectomy. Submit the authorization request before performing the procedure and include the medical-record evidence supporting medical necessity.

    • Applies to lipectomy (liposuction) for treatment of lipedema.
    • The procedure must also be performed by an authorized surgeon trained in liposuction/body contouring and in accordance with published safe lipoaspirate-volume guidelines based on body weight.
    Documentation Required

    Lipedema Lipectomy Medical-Record Documentation

    Document all eligibility elements for lipedema lipectomy in the medical record. Coverage requires every listed condition to be satisfied.

    • Clinical diagnosis of lipedema, stage I, II, or III.
    • Patient is age 18 or older and has a BMI below 30.

    Policy Distinctions

    Coverage depends on the procedure’s primary purpose. Cosmetic procedures primarily intended to improve physical appearance, provide psychological benefit, address aging, or restore form without correcting or materially improving bodily function are generally excluded. Reconstructive or medically necessary surgery may be covered when it corrects a congenital anomaly, restores body form after accidental injury, revises disfiguring and extensive neoplastic-surgery scars, provides medically necessary post-mastectomy reconstruction, or otherwise materially restores or improves bodily function.

    Policy Terms

    Cosmetic, reconstructive, and/or plastic surgery
    Primary purposeExpected primarily to improve a beneficiary's physical appearance or performed primarily for psychological purposes
    Restoration of formMay restore form without correcting or materially improving a bodily function
    Included treatmentsSurgery or treatments, including procedures, drugs, and devices
    Congenital anomaly
    TimingA condition existing at or from birth
    SignificanceA significant deviation from the common form or norm
    Exclusions and examples
    Policy Summary
    PayerDHA
    PolicyCosmetic, Reconstructive, and Plastic Surgery — General Guidelines
    Policy CodePolicy 6010.60-M
    Change TypeModified
    Effective DateMay 28, 2021
    Next Review DateN/A
    Key ActionObtain prior authorization for lipectomy (liposuction) performed to treat lipedema.
    SourceLink
    On This Page
    Covered and Excluded ServicesCoding and Eligibility ParametersAuthorization, Documentation, and Denial RisksPolicy DistinctionsPolicy Terms
    Symptoms or functional impairment: The medical record documents pain and tenderness in affected areas or bodily-function impairment, such as impaired walking or skin integrity, and liposuction will significantly contribute to the safe and effective correction or improvement of that function.Documented pain/tenderness or bodily-function impairment with expected significant functional benefit

    Examples of benefit include reduced pain or improved walking ability.

  1. Conservative treatment failure: Symptoms remain unresponsive after at least six consecutive months of adherence to conservative methods such as Complete Decongestive Therapy, compression, or weight loss.At least six consecutive months
  2. Qualified surgeon and safe technique: The procedure is performed by an authorized surgeon trained in liposuction and body contouring and following published medical guidelines for safe lipoaspirate volumes based on body weight.Authorized, trained surgeon; safe lipoaspirate volumes based on body weight
  3. Prior authorization is obtained.Required

    See Chapter 1, Section 6.1, paragraph 1.15.

    4. BMI for lipedema lipectomy
    BMI thresholdBMI < 30
    Applies toLipectomy (liposuction) for treatment of lipedema
    Requirement typeThe BMI requirement must be met along with all other specified conditions
    Conservative treatment before lipedema lipectomy
    Required durationAt least six consecutive months
    Treatment responseSymptoms must remain unresponsive
    Conservative methodsComplete Decongestive Therapy (CDT), compression, or weight loss
  4. Pain and tenderness in affected areas or bodily-function impairment, such as impaired walking or skin integrity, is documented; explain how liposuction is expected to significantly improve or safely correct the impairment, such as reducing pain or improving walking ability.
  5. Symptoms have remained unresponsive despite at least six consecutive months of adherence to conservative treatment, such as Complete Decongestive Therapy (CDT), compression, or weight loss.
  6. Identify the authorized, appropriately trained surgeon and document adherence to published medical guidelines for safe lipoaspirate volumes based on body weight.
    7. Documentation Required

    Reduction Mammoplasty Documentation Required

    Reduction mammoplasty is excluded unless the record establishes that large pendulous breasts caused intractable pain that was not amenable to other forms of treatment.

    • Document the intractable pain, its relationship to the large pendulous breasts, and the failure or inadequacy of other treatment options before requesting coverage.
    Documentation Required

    Functional Impairment Documentation

    Document the functional or reconstructive indication for procedures subject to these exclusions. Blepharoplasty requires significant impairment of vision, while rhinoplasty must correct a bodily function.

    • For blepharoplasty, document significant visual impairment and the clinical findings establishing that the procedure will correct it.
    • For rhinoplasty, document the bodily-function problem being corrected; rhinoplasty for appearance alone is excluded.
    • Septoplasty is covered when performed to correct airway obstruction.
    Denial Risk

    Primarily Cosmetic or Excluded Procedure

    Expect denial when a cosmetic, reconstructive, or plastic surgery procedure is primarily intended to improve appearance rather than restore bodily function or address a covered condition. When the procedure does not qualify for benefits, all related services and supplies, including institutional costs, are excluded.

    • Excluded indications include primarily psychological or psychiatric reasons, the aging process, personal reasons, improvement of an obvious feature considered normal and acceptable for the patient's age or background, and elective correction of minor dermatological blemishes, marks, or minor anatomical anomalies.
    • Body contouring and panniculectomy performed primarily for body sculpture or cosmesis are excluded unless panniculectomy is medically necessary.
    • Other listed exclusions include augmentation mammaplasty except under specified covered conditions, otoplasty for protruding or prominent ears, cosmetic chemical peels, tattoo removal, hair transplants, electrolysis or laser hair removal, and cosmetic procedures performed as part of gender-affirming surgery.
    Denial Risk

    Lipedema Lipectomy Criteria Not Met

    Lipedema lipectomy may be denied when any required eligibility condition is absent or not documented. Coverage requires all criteria, not merely a diagnosis of lipedema.

    • Required elements include stage I–III lipedema, age 18 or older, BMI below 30, documented pain/tenderness or bodily-function impairment with expected functional improvement, and failure to respond to at least six consecutive months of conservative treatment.
    • The procedure must be medically necessary and appropriate, performed by an authorized and trained surgeon using safe lipoaspirate-volume practices, and authorized in advance.
    Denial Risk

    Untimely Post-Trauma Procedure

    Benefits are limited to covered cosmetic, reconstructive, and plastic surgery performed no later than December 31 of the year following the year in which the related accidental injury or surgical trauma occurred.

    • A procedure performed after the applicable deadline may be denied as untimely.
    • Authorized post-mastectomy reconstructive breast surgery has no time limitation between mastectomy and reconstruction.
    • Special consideration may apply to children who require a growth period.
    Denial Risk

    Rhytidectomy Excluded Unless Trauma-Related

    Rhytidectomy is excluded unless performed to treat facial palsy, significant facial burns, or other significant major facial trauma. Document the qualifying condition and reconstructive purpose in the medical record.

    • The exclusion applies to CPT 15824–15826, 15828, and 15829.
    • Rhytidectomy performed for aging-related or cosmetic improvement is not covered.
    Other than a common racial or ethnic feature; examples include cleft lip and syndactyly, while dental anomalies and gender dysphoria are excluded