Commercial

Medical Policy

Notification

Cosmetic Procedures

Notification Issued Date:

This version of the policy will become effective 07/01/2023.

This policy has been updated to communicate that the Company’s coverage position for injectable dermal fillers (e.g., Sculptra, Radiesse) has changed from Potentially Cosmetic to Always Cosmetic. Therefore, they are not eligible for reimbursement consideration.

Title:

Cosmetic Procedures

Policy #:

12.01.03b

Policy

POTENTIALLY COSMETIC PROCEDURES

Services that are determined to be cosmetic, following medical necessity review, are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration. The following are services that may be considered cosmetic (this list is subject to change):

Blepharoplasty
Body-contouring procedures (e.g., liposuction, lipectomy)
Botox injections
Calf implantation
Cervicoplasty/platysmaplasty
Chin augmentation (genioplasty, mentoplasty)
Chemical peels
Cricothyroid approximation
Collagen injections
Collagenase clostridium histolyticum injections
Correction of diastasis recti abdominis
Dermabrasions/chemical peels
Excision of redundant skin
Facial masculinizing/feminizing surgeries (e.g., facial bone reduction)
Forehead reduction
Gluteal augmentation (e.g., silicone implants, fat transfer, fat grafting)
Gynecomastia surgery
Hair reconstruction (e.g., hair removal/electrolysis, hair transplantation, wigs)
Labiaplasty
Laryngoplasty
Lip reduction/enhancement
Orthognathic procedures
Otoplasty
Panniculectomy
Pectoral implantation
Pulsed-dye laser treatment
Reduction mammoplasty
Rhinoplasty
Rhytidectomy
Scar revision
Septoplasty
Trachea shave/reduction thyroid chondroplasty
Treatment of telangiectasia (spider veins), varicose veins
Tattooing (nontherapeutic)
Voice modification surgery

Note: Services performed to revise the outcome of a previous cosmetic procedure are considered cosmetic and, therefore, a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

ALWAYS COSMETIC PROCEDURES

The following are not covered by the Company because they are always considered cosmetic. Services and drugs that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration (this list is subject to change):

Abdominoplasty
Injectable dermal fillers (e.g., Sculptra, Radiesse)
Kybella (deoxycholic acid)
Qwo (collagenase clostridium histolyticum)

Note: Services performed to revise the outcome of a previous cosmetic procedure are considered cosmetic and, therefore, a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

CONDITIONS THAT MAY BE CONSIDERED MEDICALLY NECESSARY

The treatment of medical and surgical complications resulting from cosmetic procedures is considered medically necessary and, therefore, covered when, if left untreated, the complications would endanger the health of the individual. Treatment is covered and eligible for reimbursement consideration by the Company based on the medical necessity for acute conditions such as, but not limited to:

Deep vein thrombosis
Hemorrhage
Incisional hernia
Infection
Myocardial infarction
Wound dehiscence

Services performed due to a condition resulting from an accident or to a functional impairment resulting from a covered disease, injury, or congenital birth defect may be considered medically necessary and, therefore, covered.

For medically necessary criteria for noncosmetic uses of a potentially cosmetic procedure, specific Company policies may exist; please refer to such individual policies for criteria that address cosmetic services.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, cosmetic procedures are a benefit contract exclusion for all Company products.

FINANCIAL RESPONSIBILITY

Members are financially responsible for all costs associated with all cosmetic procedures.

Description

COSMETIC PROCEDURES

Cosmetic procedures are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiologic function.

References

American Academy of Dermatology (AAD). Position statement on the definitions of cosmetic and reconstructive surgery. [AAD Web site]. 08/07/2010. Available at: PS-Definitions of Cosmetic & Reconstructive Surgery.pdf (aad.org). Accessed January 31, 2024.

American Academy of Otolaryngology–Head and Neck Surgery. Facial plastic surgery. Patient health information. [ENT Web site]. 2022. Available at: http://www.entnet.org/content/facial-plastic-surgery-0. Accessed January 31, 2024.

American Board of Cosmetic Surgery. Cosmetic surgery vs. plastic surgery. [American Board of Cosmetic Surgery Web site]. 2022. Available at:
http://www.americanboardcosmeticsurgery.org/patient-resources/cosmetic-surgery-vs-plastic-surgery/. Accessed January 31, 2024.

Company Benefit Contracts.

Centers for Medicare & Medicaid Services (CMS). Department of Health and Human Services. Items and services that are not covered under the Medicare program. [CMS Web site]. June 2022. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Items-and-Services-Not-Covered-Under-Medicare-Booklet-ICN906765.pdf. Accessed January 31, 2024.

Centers for Medicare & Medicaid Services (CMS). Medicare benefit policy manual. Chapter 16 General exclusion from coverage. [CMS Web site]. 11/6/14. Available at: Medicare Benefit Policy Manual (cms.gov). Accessed January 31, 2024.

Endo Aesthetics LLC. Patient information: Qwo. [Endo Web site]. 07/2020. Available at: https://d1skd172ik98el.cloudfront.net/48a33315-f594-4269-8043-8853d10fb7bf/2be4acaf-4b1b-4b08-85ba-42a5befcec98/2be4acaf-4b1b-4b08-85ba-42a5befcec98_source__v.pdf. Accessed January 31, 2024.

Endo Aesthetics LLC. Qwo Web site. 10/2022. Available at: https://www.qwo.com/. Accessed January 31, 2024.

Endo International plc. 12/06/2022. Press release: Endo to Cease Production and Sale of Qwo® (collagenase clostridium histolyticum-aaes). [Endo Web site]. Available at: Endo to Cease Production and Sale of Qwo® (collagenase clostridium histolyticum-aaes) | Endo International plc. Accessed January 31, 2024.

Endo International plc. 07/06/2020. Press release: U.S. FDA Approves Qwo™ (collagenase clostridium histolyticum-aaes), the first injectable treatment for cellulite. [Endo Web site]. Available at: https://investor.endo.com/news-releases/news-release-details/us-fda-approves-qwotm-collagenase-clostridium-histolyticum-aaes. Accessed January 31, 2024.

Food and Drug Administration (FDA). Prescribing information: Qwo. [FDA Web site]. 07/2020. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/761146s000lbl.pdf. Accessed January 31, 2024.

Novitas Solutions. Local Coverage Determination (L35090). Cosmetic and Reconstructive Surgery. [Novitas Solutions Website]: Original 10/01/2015 (Revised: 07/11/2021). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35090&ver=69&Date=&DocID=L35090&SearchType=Advanced&bc=EgAAAAIAAAAA&. Accessed January 31, 2024.

Novitas Solutions. Local Coverage Article (A56587). Billing and Coding: Cosmetic and Reconstructive Surgery. [Novitas Solutions Website]: Original 05/30/2019 (Revised: 07/11/2021). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=56587&ver=37. Accessed January 31, 2024.

US Food and Drug Administration (FDA) Cosmetic Devices. Dermal fillers approved by the Center for Devices and Radiological Health. [FDA Web site]. Available at: https://www.fda.gov/medical-devices/aesthetic-cosmetic-devices/fda-approved-dermal-fillers. Accessed January 31, 2024.

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 12.01.03b:

02/21/2024

This policy has been reviewed and reissued in accordance with the Company's continuing position on Cosmetic Procedures.

07/01/2023

Revisions From 12.01.03a:

11/16/2022	This policy has been reviewed and reissued in accordance with the Company's continuing position on Cosmetic Procedures.
06/16/2021	This policy has been reissued in accordance with the Company's annual review process.
11/23/2020	This version of the policy will become effective 11/23/2020. The policy has been updated to communicate that the prescription brand drug Qwo (collagenase clostridium histolyticum) is not covered by the Company because it is considered a cosmetic service. Services that are cosmetic are a benefit contract exclusion for all products of the Company and are not eligible for reimbursement consideration.

Revisions From 12.01.03:

05/22/2019	This policy has been reviewed and reissued in accordance with the Company's continuing position on Cosmetic Procedures.
10/24/2018	This policy has been reissued in accordance with the Company's annual review process.

Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date:

7/1/2023

Version Issued Date:

6/30/2023

Version Reissued Date:

2/21/2024