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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 4
Section 2.1
Cosmetic, Reconstructive, And Plastic Surgery - General Guidelines
Issue Date:  October 22, 1985
Authority:  32 CFR 199.2(b), 32 CFR 199.4(e)(8), (g)(24) and 10 USC 1079(a)(12)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-18, February 21, 2018
Cosmetic, reconstructive, and/or plastic surgery is defined as surgery or treatments (including procedures, drugs, and devices) which can be expected primarily to improve the physical appearance of a beneficiary, and/or which is performed primarily for psychological purposes, and/or which restores form, but does not correct or materially improve a bodily function.
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.
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.
3.4  Augmentation mammaplasty (except for those conditions listed in paragraph 2.0 and in Section 5.6).
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.
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