mp-116 - Medical Policies - Alabama
Policy Number: MP-116
Latest Review Date: March 2022
Otoplasty may be considered medically necessary for Ear protrusion when ALL of the following medical criteria are met:
- Ear protrudes more than 20mm or more than 30 degrees from the temporal/temporomastoid surface of the head;
- Pre-operative photos to include right and left laterals of head, facial frontal views to demonstrate protrusion are required;
- Must be at least 4 years of age.
Otoplasty may be considered medically necessary for Constricted ear/Lop ear when ALL of the following medical criteria are met:
- Constricted ear/Lop ear deformity will require photographs to include right and left laterals of head, facial frontal views;
- Must be at least 4 years of age.
DESCRIPTION OF PROCEDURE OR SERVICE:
Otoplasty is a description of surgical procedures designed to give the auricle a more natural and anatomic appearance. Otoplasty is specifically designed to “pin back” or reposition protruding ears and create natural looking folds and convolutions. All current otoplasties are effective in reducing the prominence of the ear but one technique may be better than another for a special problem, and each technique is characterized by certain incidental changes in the nature or the shape of the auricle.
Prominent ears are a congenital abnormality in which the ears tend to project excessively from the skull. This condition may occur as a result of an inadequately formed antihelix (i.e., the outer frame of the auricle), an overdeveloped or excessively deep concha (i.e., hollow portion of the outer ear), or a combination of these conditions. Normal prominence is defined as 1.2–2.0 cm from the post-auricular scalp to the lateral aspect of the superior helix. Ear prominence is typically defined as a protrusion of the helix 2 cm or more from the postauricular scalp. Otoplasty performed to correct prominent ears involves recreating an antihelical fold and possibly in setting or resecting the concha to decrease the prominence. The normal external ear forms an angle of about 23 degrees with the temporal surface of the head. If the angle is more obtuse, the ears may appear excessively prominent on a full-face view.
The constricted ear deformity, often called “cup ear” or “lop ear”, involves a loss of height of the ear. The constriction may be mild to severe and each deformity should be addressed individually. This may also be referred to as prominent ear deformity.
Literature review performed through March 25, 2022.
Summary of Evidence:
The primary goal of surgical correction for prominent/protruding ears is improvement of physical appearance (i.e., cosmesis). Complications associated with otoplasty and/or external ear reconstructive procedures include bleeding, infection and possibly pneumothorax if a rib graft is used.
Practice Guidelines and Position Statements:
American Academy of Pediatrics (AAP): Guidelines and/or position statements from the AAP do not comment on the performance of otoplasty for treatment of external ear deformities.
American Society of Plastic Surgeons (ASPS): According to the ASPS, otoplasty is considered a reconstructive surgery that may be performed in children or adults, although the procedure is more common in children (ASPS, 2005; Reaffirmed June 2015).
Otoplasty, protruding ears, prominent ears, ears, lop ear
APPROVED BY GOVERNING BODIES:
Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.
ITS: Home Policy provisions apply
FEP contracts: FEP does not consider investigational if FDA approved and will be reviewed for medical necessity. Special benefit consideration may apply. Refer to member’s benefit plan.
Otoplasty, protruding ear, with or without size reduction
- American Academy of Facial Plastic and Reconstructive Surgery. (2016). Ear surgery. Retrieved March 22, 2016 from http://www.aafprs.org.
- American Society of Plastic and Reconstructive Surgeons. Position Paper: Ear Deformity: Prominent Ears, adopted January, 1998, http://www.plasticsurgery.org/medical_professionals/publications.
- American Society of Plastic Surgeons (ASPS). Ear deformity: prominent ears: recommended criteria for third-party payer coverage [position paper]. Socioeconomic Subcommittee. Approved by ASPS Board of December 2005. Reaffirmed June 2015. Accessed March 25, 2022. Available at URL address: http://www.plasticsurgery.org/for-medical-professionals/legislation-and-advocacy/health-policyresources/recommended-insurance-coverage-criteria.html.
- British Association of Plastic Reconstructive and Aesthetic Surgeons. (2016). Ear Surgery. Retrieved March 22, 2016 from http://www.bapras.org.uk/public/patient-information/surgery-guides/ear-surgery.
- Ear Plastic Surgery. American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS). Patient Health Information. Ear Plastic Surgery. © Copyright 2021. American Academy of Otolaryngology — Head and Neck Surgery. Accessed March 25, 2022. Available at URL address: https://www.enthealth.org/be_ent_smart/ear-plastic-surgery/
- Furnas, David W. Ear, prominent ear, http://www.emedicine.com/plastic/topic454.htm.
- Furnas, David W. Otoplasty, Grabb and Smith’s Plastic Surgery, Fifth Edition, Chapter 36, pp. 431-438.
- National Institute for Health and Care Excellence. (2012, March). Incisionless otoplasty. https://www.nice.org.uk.
- Pawar, S., Koch, C. and Murakami, C. (2015). Treatment of prominent ears and otoplasty: a contemporary review. JAMA Facial & Plastic Surgery, 17 (6), 449-54.
- Sclafani, Anthony P. and Ranaudo, Jeffrey. Otoplasty, http://www.emedicine.com/ent/topic110.htm.
- Spira, Melvin. Otoplasty: What I do now-A 30-year perspective, Plastic Reconstructive Surgery, September 1999, Vol. 104(3), pp. 834-840, http://www.gateway1.ovid.com/ovidweb.cgi.
Medical Policy Group, May 2003 (1)
Medical Policy Administration Committee, May 2003
Available for comment July 1-August 14, 2003
Available for comment August 28-October 13, 2003
Medical Policy Group, November 2004
Medical Policy Group, May 2006 (1)
Medical Policy Group, November 2008 (1)
Medical Policy Group, May 2010 (1) No policy changes
Medical Policy Group, September 2012 (3): Active Policy but no longer scheduled for regular
literature reviews and updates.
Medical Policy Group, October 2019 (6): Updates to Description, Key Points, Practice
Guidelines and References.
Medical Policy Group, March 2021 (3): Minor updates to Key Points, and Practice Guidelines and Position Statements. A peer-reviewed literature analysis was completed and no new information was identified that would alter the coverage statement of this policy.
Medical Policy Group, March 2022 (3): 2022 Updates to Key Points, and References. A peer-reviewed literature analysis was completed and no new information was identified that would alter the coverage statement of this policy.
Medical Policy Group, May 2022 (6): Clarification to Policy Statement. No change to policy intent.
This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.
The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.
As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.
The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:
1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.
Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:
1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.