2.0
POLICY
2.1 Benefits
are 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
gender
dysphoria (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 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 is given
to cases involving children who may require a growth period.
3.0 EXCLUSIONS
The following is a partial
list of cosmetic, reconstructive, and 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 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, ethnic, 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 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.
3.19 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 or plastic
surgery procedure does not qualify for benefits, all related services
and supplies are excluded, including any institutional costs.