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.