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 shall not include
anomalies relating to teeth (including malocclusion or missing tooth
buds) or structures supporting the teeth, or to any form of Gender Dysphoria
(GD) (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 Lipectomy
(liposuction) may be covered for the treatment of lipedema when
all of the following conditions are met:
• Clinical diagnosis of lipedema
stage I, II, or III;
• Aged 18 years or older;
• BMI < 30;
• Medical record contains documented
pain and tenderness in affected areas or bodily function impairment
(e.g., walking, skin integrity) and the liposuction will significantly
contribute to the safe and effective correction or improvement of
the bodily function (e.g., reduced pain, improved walking ability);
• Symptoms unresponsive to at least
six consecutive months of adherence to conservative methods such
as Complete Decongestive Therapy (CDT), compression, or weight loss;
• Procedure is performed by an authorized
surgeon trained in liposuction/body contouring and following published
medical guidelines for safe lipoaspirate volumes based on body weight;
and
• Prior authorization is required.
See also
Chapter 1, Section 6.1, paragraph 1.16.
2.1.8 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) 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.
