2.0
POLICY
2.1 Benefits
may be allowed for cosmetic, reconstructive, and/or plastic surgery,
including otherwise covered services and supplies, under the following
circumstances:
2.1.1 Correction of a congenital anomaly.
Note: A congenital anomaly is defined as a condition
existing at or from birth that is a significant deviation from the
common form or norm and is other than a common racial or ethnic
feature. Two examples of congenital anomalies are: cleft lip and
syndactyly. Congenital anomalies do not include anomalies relating
to teeth (including malocclusion or missing tooth buds) or structures
supporting the teeth, or to any form of sex gender confusion (see
32 CFR 199.2(b) for full definition of congenital anomaly).
2.1.2 Restoration
of body form (including revision of scars) following an accidental
injury; or
2.1.3 Revision of disfiguring and extensive scars
resulting from neoplastic surgery.
2.1.4 Post-mastectomy
breast reconstruction is covered when following a medically necessary mastectomy
(see Section 5.2).
2.1.5 Surgery
to correct pectus excavatum is covered as correction of a congenital
anomaly when the defect is more than a minor anatomical anomaly.
2.1.6 Liposuction
when used as a substitute for the scalpel is covered when medically
necessary, appropriate, and the standard of care.
2.1.7 Panniculectomy
performed in conjunction with other abdominal or pelvic surgery
is covered when medical review determines that the procedure significantly
contributes to the safe and effective correction or improvement
of a bodily function (e.g., integrity of the skin).
2.2 Benefits
are authorized for other surgeries when the surgery is determined
to be a medically necessary procedure, integral to the restoration
of a bodily individual function (e.g., panniculectomy for chronic
skin ulceration).
2.3 Benefits are limited to those
cosmetic, reconstructive, and/or plastic surgery procedures performed
no later than December 31 of the year following the year in which
the related accidental injury or surgical trauma occurred. There
is an exception for authorized postmastectomy reconstructive breast
surgery for which there is no time limitation between mastectomy
and reconstruction. Also, special consideration will be given to
cases involving children who may require a growth period.
3.0 EXCLUSIONS
The following is a partial list of cosmetic,
reconstructive, and/or plastic surgery procedures which are excluded.
This list is not all-inclusive.
3.1 Dental congenital anomalies
such as absent tooth buds or malocclusion.
3.2 Cosmetic, reconstructive and/or
plastic surgery procedures performed primarily for psychological
or psychiatric reasons or as a result of the aging process.
3.3 Procedures
performed for elective correction of minor dermatological blemishes
and marks or minor anatomical anomalies.
3.5 Any procedure
performed for personal reasons, to improve the appearance of an
obvious feature or part of the body which would be considered by
an average observer to be normal and acceptable for the patient’s
age and/or ethnic and/or racial background.
3.6 Face lifts,
chemical peels, and other procedures related to the aging process.
3.7 Reduction
mammoplasties (unless there is medical documentation of intractable
pain not amenable to other forms of treatment, as the result of
large pendulous breasts).
3.8 Panniculectomies primarily
performed for body sculpture procedures/reasons of cosmesis (unless
it is medically necessary).
3.9 Blepharoplasty (except when
performed for correction of documented significant impairment of
vision).
3.10 Rhinoplasties except when performed to correct
a bodily function. Septoplasty is covered when performed to correct
airway obstruction.
3.11 Otoplasty for protruding and/or
prominent ears. Otoplasty for microtia, lop ear, constricted ear, and
other congenital ear deformities may be covered.
3.12 Chemical
peeling (exfoliation) for any of the following:
• Treatment of aging
skin.
• Treatment
or removal of facial wrinkles.
• Treatment of acne
or of acne scars.
3.13 Revision of scars resulting
from surgery and/or a disease process, except disfiguring and extensive
scars resulting from neoplastic surgery.
3.14 Dermabrasion of the face (except
when performed as part of surgery to restore body form following
accidental injury or revision of disfiguring and extensive scars
resulting from neoplastic surgery).
3.15 Removal of tattoos.
3.16 Hair transplants.
3.17 Electrolysis
or laser hair removal.
3.18 Insertion of prosthetic testicles
for transsexualism, or such other conditions as gender dysphoria.
3.19 Body contouring.
3.20 Rhytidectomy
(Current Procedural Terminology (CPT) procedure codes 15824 - 15826,
15828, and 15829) except for treatment of facial palsy or significant
facial burns or other significant major facial trauma.
3.21 Facial
implants (except when performed as part of surgery to restore body
form following accidental injury or revision of disfiguring and
extensive scars resulting from neoplastic surgery).
3.22 Face transplant,
maxillary transplant, and facial Composite Tissue Allotransplantation
(CTA).
3.23 When it is determined that a cosmetic, reconstructive
and/or plastic surgery procedure does not qualify for benefits,
all related services and supplies are excluded, including any institutional
costs.