Currentsierra health and lifePolicy N/A

Plastic and Reconstructive Surgery Services — Coverage Criteria

Policy governing coverage, referral, and medical necessity criteria for plastic and reconstructive surgical services (breast reconstruction, reduction mammoplasty, excess skin removal after massive weight loss, hidradenitis-related excision, gynecomastia, and referral guidance) for Sierra Health and Life members in Nevada.

Policy Summary

Payersierra health and life

PolicyPlastic and Reconstructive Surgery Services — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain and document prior authorization with BMI <35, nicotine-free status for 6 weeks, and required photographic and Schnur chart documentation for breast reduction evaluations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=18minimum age

BMI <35BMI requirement

6 weekstobacco abstinence

>22%Schnur threshold

3+hidradenitis referral

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Coverage Criteria for Plastic & Reconstructive Surgery

Breast Reduction (Reduction mammoplasty) — Covered when ALL criteria met

Covered when ALL of the following are met:

Age and preparatory requirements: Patient is at least 18 years of age or breast growth is complete (if under 18 must have parent consent); patient must be nicotine free for 6 weeks prior to scheduling a consultation; patient must have a documented BMI below 35 prior to scheduling a consultation.age >=18; nicotine-free 6 weeks; BMI <35

Symptoms and failed conservative care: Macromastia is causing at least ONE of the following with documented failure of at least one continuous three-month trial of appropriate medical management: shoulder/upper back/neck pain and/or ulnar nerve palsy with no other identified etiology; intertrigo/dermatitis/eczema; or hidradenitis at the inframammary fold.>=1 symptom with >=3 months failed medical management

Photographic and Schnur documentation: Pre-operative photographs confirm significant breast hypertrophy and shoulder grooving from bra straps and/or intertrigo if present; average weight of tissue planned to be removed per breast is above the 22nd percentile on the Schnur Sliding Scale for the patient’s BSA.Schnur >22nd percentile

If plotted between 5th–22nd percentile, decision is case-by-case; below 5th percentile considered cosmetic.

Breast Reconstruction after Mastectomy — Covered (reconstructive)

Reconstruction is to be determined between plastic surgeon and general surgeon.

Referral and determination: Initial exam includes evaluation and referral to a general surgeon for biopsy when indicated. If the general surgeon deems the patient an appropriate candidate for reconstruction, refer to plastic surgery for evaluation. Reconstruction may be immediate or delayed and includes procedures to reestablish symmetry (eg, augmentation, reduction, mastopexy).

Surgical planning on the non-involved side to achieve symmetry is determined by the plastic surgeon after consultation.

Excess Skin after Massive Weight Loss (Pannus removal) — Covered only for specific conditions

Removal of offending pannus is covered when ALL conditions below are met:

Indication and limitation: There is transdermal wound ulceration that is not responsive to conservative wound care; removal is limited to the offending pannus/skin only; other procedures are considered cosmetic and not covered.non-healing transdermal ulceration after conservative care

Preoperative requirements: Patient must be nicotine free for 6 weeks prior to scheduling a consultation and have a documented BMI below 35 prior to scheduling a consultation.nicotine-free 6 weeks; BMI <35

Hidradenitis Management and Surgical Referral

Treatment progression required before plastic surgery excision:

Conservative therapy first: Primary care should evaluate and treat with conservative measures including oral or IV antibiotics and local wound care as indicated. If symptoms are recurrent with more than 3 courses of antibiotics and local wound care in one year, refer to dermatology for consideration of biologic therapy (eg, Humira).>3 courses/year

Failure of biologic therapy: If biologic (Humira) therapy fails after 1 year, referral to Plastic Surgery for consideration of surgical excision is appropriate.Humira failure after 1 year

Gynecomastia

Coverage stance for gynecomastia:

Malignancy excluded: Patients should be examined and referred for evaluation for potential breast malignancy; if the lesion is suspicious for malignancy, excision (referred to a general surgeon) is warranted. If there is no suspicion of malignancy, gynecomastia is considered cosmetic and is not a covered benefit.suspicion of malignancy vs no suspicion

Procedures that the plan considers cosmetic and not covered include a range of elective interventions where no functional impairment or medical necessity is documented. Examples include: treatment of acne scars, treatment of gynecomastia when there is no suspicion of malignancy, repair of torn earlobes, and removal or revision related to complications from cosmetic enhancements (e.g., tattoos, body piercings). Additionally, procedures beyond removal of the offending pannus after massive weight loss are considered cosmetic unless the specific pannus is causing a non-healing transdermal ulceration unresponsive to conservative care.

Specific exclusions and scenarios commonly denied as inappropriate referrals include: scar revisions when the scar does not cause a limitation of function; treatment of keloid scars; removal of uncomplicated cysts, skin tags, or lipomas (unless the mass is infected, rapidly enlarging over recent months, or produces pain not controlled with OTC medications, in which case removal may be considered with supporting documentation); and treatment of verrucous lesions and pigmented lesions without evidence of malignancy.

Coding Guidance and Clinical Thresholds

Schnur Sliding Scale percentile — thresholds for reconstructive vs cosmetic

Reconstructive thresholdAverage planned tissue removal per breast above the 22nd percentile on the Schnur Sliding Scale supports a reconstructive indication (with functional impairment).

Cosmetic thresholdIf the amount plots below the 5th percentile on the Schnur chart, the procedure is considered cosmetic.

Indeterminate rangeAmounts plotting between the 5th and 22nd percentiles may be considered reconstructive or cosmetic on a case-by-case review.

Basis of assessmentSchnur Sliding Scale is plotted using planned tissue removed per breast adjusted for the patient’s body surface area (BSA).

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior authorization and preoperative requirements

Prior authorization is required for evaluations for reduction mammoplasty and panniculectomy; document nicotine-free status for 6 weeks and a BMI below 35 prior to scheduling consultation. For breast reduction, provide planned tissue removal per breast plotted on the Schnur Sliding Scale (average weight per breast) to demonstrate whether the amount plots above the 22nd percentile when applicable.

Nicotine-free for 6 weeks prior to scheduling a consultation (breast reduction and panniculectomy).
Documented BMI below 35 prior to scheduling a consultation (breast reduction and panniculectomy).
For breast reduction, include average weight of tissue planned to be removed per breast plotted on the Schnur Sliding Scale.

Step Therapy

Step therapy for hidradenitis

Providers must ensure conservative management is attempted by the PCP first: treat hidradenitis with antibiotics (oral or IV) and local wound care. If the patient has more than three courses of antibiotics/local wound care in one year, refer to dermatology for treatment with Humira; if Humira fails after one year, then referral to plastic surgery for possible excision is appropriate.

Background and Definitions

Reconstructive plastic surgery is intended to restore form and function after disease, injury, or treatment. Examples addressed in this policy include breast reconstruction after mastectomy and removal of an offending pannus when there is non-healing transdermal wound ulceration following massive weight loss that has not responded to conservative wound care. Reconstruction decisions (timing and specific procedures such as augmentation, reduction, or mastopexy to reestablish symmetry) are made through coordination between the plastic surgeon and the general surgeon. Conversely, purely cosmetic concerns or procedures without documented functional impairment are not covered.

Reconstructive surgery (breast) definition

DefinitionSurgical procedure performed following a mastectomy on one or both breasts to reestablish symmetry between the two breasts; includes augmentation mammoplasty, reduction mammoplasty, and mastopexy.

TimingReconstruction may be immediate or delayed; timing is determined between the plastic surgeon and the general surgeon.

Care coordinationInitial exam includes evaluation and referral to a general surgeon for biopsy; if deemed appropriate, refer to plastic surgery for evaluation.

Symmetry planning