LCD L39506: Cosmetic and Reconstructive Surgery

• According to the American Society of Plastic and Reconstructive Surgeons, the specialty of plastic surgery includes reconstructive and cosmetic procedures:

Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease. It is generally performed to improve function, may also be done to approximate a normal appearance, and may be covered as surgery is considered reconstructive in nature.

Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem. Please refer to CMS IOM Publication 100-02, Medicare Benefit Policy Manual , Chapter 16: Section 120 for detailed information.

• Corrective facial surgery will be considered cosmetic rather than reconstructive when there is no functional impairment present. However, some congenital, acquired, traumatic or developmental anomalies may not result in functional impairment, but are so severely disfiguring (e.g. but not limited to severe burns or repair of the face following a serious automobile accident) as to merit consideration for corrective surgery.

• Treatment of complications arising from cosmetic surgery will be considered reasonable and necessary as long as infection, hemorrhage or other serious documented medical complication occurs, and the beneficiary has been officially discharged from the facility.

Per the Medicare Benefit Policy Manual cosmetic surgery or expenses incurred in connection with such surgery, for the sole purpose of improving one’s appearance, is not covered.

Indications for specific surgical procedure

• Breast reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is covered.

• Removal or revision of a breast implant whether placed for reconstructive or cosmetic reasons, is considered medically necessary when it is removed for one of the following reasons: 1

• Mechanical complication of breast prosthesis; including rupture or failed implant, and/or implant extrusion.

• Infection or inflammatory reaction due to a breast prosthesis; including infected breast implant, or rejection of breast implants.

• Other complication of internal breast implant; including siliconoma, granuloma, interference with diagnosis of breast cancer, and/or painful capsular contracture with disfigurement.

• Breast Reduction is the surgical reshaping of the breasts to reduce, or lift enlarged or sagging breasts. Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit.

Macromastia (breast hypertrophy) is an increase in the volume and weight of breast tissue relative to the general body habitus. Breast hypertrophy may adversely affect other body systems: musculoskeletal, respiratory, and integumentary. Unilateral hypertrophy may result in symptoms following contralateral mastectomy.

Medical necessity for a breast reduction is limited to circumstances in which:

• There are signs and/or symptoms resulting from the enlarged breasts (macromastia) that have not responded adequately to non-surgical interventions,

• To improve or correct asymmetry following cancer surgery on one breast.

Note: either the involved breast or contralateral breast may be treated to achieve symmetry.

Note: For coverage indications for contralateral reconstruction of an unaffected breast following a medically necessary mastectomy, refer to the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §140.2.

Non-surgical interventions preceding breast reduction should include as appropriate, but are not limited to, the following:

• Determining the macromastia is not due to an active endocrine or metabolic process.

• Determining the symptoms are refractory to appropriately fitted supporting garments, or following unilateral mastectomy, persistent with an appropriately fitted prosthesis or reconstruction therapy at the site of the absent breast.

• Determining that dermatologic signs and/or symptoms are refractory to, or recurrent following, a completed course of medical management.

A medically reasonable and necessary breast reduction could be indicated in the presence of significantly enlarged breasts and the presence of at least one of the following signs and/or symptoms:

• Back, neck or shoulder pain from macromastia and unrelieved by 6 months of:

- Conservative analgesia,

- Supportive measures (garment, etc.),

- Physical Therapy, or

• Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity, or

• Intertriginous maceration or infection of the inframammary skin refractory related to dermatologic measures.

• Permanent shoulder grooving with skin irritation by supporting garment (bra strap).

The amount of breast tissue to be removed must be proportional to the body surface area (BSA) per the Schnur18 scale below. If the individual’s body surface area and weight of breast tissue removed fall above the 22 nd percentile, then the surgery is considered medically reasonable and necessary with the appropriate criteria. If only one breast meets the Schnur scale criteria; breast tissue may be removed from the other breast in order to achieve symmetry.

Schnur Scale:

Body Surface

Area (m2)

Average grams of tissue per breast to

be removed

1.40-1.50

218-260

1.51–1.60

261-310

1.61-1.70

311-370

1.71-1.80

371-441

1.81-1.90

442-527

1.91-2.00

528-628

2.01-2.10

629-750

2.11-2.20

751-895

2.21-2.30

896-1068

2.31-2.40

1069-1275

2.41-2.50

1276-1522

2.51-2.60

1523-1806

2.61-2.70

1807-2154

2.71-2.80

2155-2568

2.81-2.90

2569-3061

2.91-3.00

3062-3650

Mastectomy for gynecomastia

Gynecomastia is the excessive growth of the male mammary glands. These conditions can cause significant clinical manifestations when the excessive breast weight adversely affects the supporting structures of the shoulders, neck, and trunk.

Mastectomy with nipple preservation or reduction mammoplasty is considered reconstructive and a covered service for males with gynecomastia Grade III and IV or abnormal breast development with redundancy.

• Persists more than 3 to 4 months after the pathological causes are ruled out (e.g., not limited to testosterone deficiency, testicular tumor, liver disease, or drug induced). 2

• Persists after 3 to 4 months of unsuccessful medical treatment for pathological gynecomastia. 3

• Pain or tenderness directly related to the breast tissue which has a clinically significant impact upon activities of daily living.

• Clinical symptoms refractory to a trial of analgesics or anti-inflammatory agents.

• For significant clinical manifestations when the excessive breast weight adversely affects the supporting structures of the shoulders, neck and trunk.

American Society of Plastic Surgeons’ gynecomastia scale: 3

• Grade I: Small breast enlargement with localized button of tissue that is concentrated around the areola.

• Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest.

• Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present.

• Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast

Tattooing

To correct color defects of the skin may be considered reconstructive when performed in connection with a payable post-mastectomy reconstruction, or for reconstruction following trauma or removal of cancer from an eyelid, eyebrow or lip(s).

Punch graft hair transplant may be considered reconstructive when it is performed for eyebrow(s) or symmetric hairline replacement following a burn injury, trauma or tumor removal.

Nasal surgery is defined as any procedure performed on the external or internal structures of the nose, septum or turbinate. It generally involves rearrangement or excision of the supporting bony and cartilaginous structures and incision or excision of the overlying skin of the nose.

Nasal surgery, including rhinoplasty, may be reconstructive or cosmetic in nature. Current CPT Codes do not allow distinction of cosmetic or reconstructive procedures by specific codes; therefore, categorization of each procedure is to be distinguished by the presence or absence of specific signs or symptoms.

Rhinoplasty is a procedure that changes the shape or appearance of the nose while improving or preserving the nasal airway. The primary purpose for Rhinoplasty can be functional, aesthetic, or both and may include other procedures on the paranasal sinuses, septum, or turbinates. 4

Septoplasty is a procedure used to correct deformities of the nasal septum which can often cause issues with airflow and difficulty breathing. 5

• Rhinoplasty is considered medically reasonable and necessary when the procedure is performed for correction and repair of any of the following indications:

The American Society of Plastic Surgeons explains Plastic Surgery can include both reconstructive and cosmetic procedures. 1 Typically reconstructive surgery is considered medically necessary to restore function and normal appearance, and to correct deformities that are congenital, trauma related or created by medical conditions such as cancer. Cosmetic surgery is not considered medically necessary as it is performed to reshape and adjust normal anatomy to enhance appearance. Certain conditions can be considered either reconstructive or cosmetic depending on the patient’s specific situation. An example of this is rhinoplasty which may be performed to enhance the person’s appearance which is cosmetic but also may be necessary to restore normal breathing and appearance after a trauma such as a fracture which is reconstructive. Often rhinoplasty is performed with other procedures which involve the nasal septum, nasal valve, nasal turbinates, or the paranasal sinuses. When adjunctive procedures are performed that do not change the nasal shape or appearance, they do not meet the definition of rhinoplasty. Rhinoplasty performed to address functional abnormalities may inadvertently change the shape or appearance of the nose.

Rhinoplasty/Septoplasty

Ishii et al 4 created clinical guidelines to provide evidence-based recommendations for the treatment of patients who are candidates for rhinoplasty. Rhinoplasty ranks among the most commonly performed cosmetic surgery in the United States. Rhinoplasty should be considered more than just for cosmetic reasons as it is often medically necessary to improve nasal respiration and relieve any congenital or acquired airway obstructions. While Rhinoplasty may be performed to address a functional abnormality, it may also change or enhance the appearance of the nose. Rhinoplasty is often performed with adjunctive procedures that involve the nasal septum, nasal valve, nasal turbinates, or the paranasal sinuses. When these accompanying procedures are performed without an impact on the nasal shape or appearance, they do not meet the definition of Rhinoplasty.

These guidelines were created by a Guideline Development Group that consisted of 16 members representing experts in plastic surgery, facial plastic and reconstructive surgery, otolaryngology, otology, rhinology, sleep medicine, psychiatric, advanced practice nursing, and consumer advocacy. Three literature searches were performed from May 2015 through December 2015 to identify clinical practice guidelines, systematic reviews, and randomized controlled trials. After all exclusion methods the literature resulted in 1 guideline, 22 systematic reviews, and 19 randomized controlled trials. This information was used to gather evidence, relevant treatments, and outcomes.