Latest Review Date: January 2024

Category:  Administrative                                                     

POLICY:

Reconstructive surgery may be considered medically necessary when performed primarily to restore or improve the way the body works or correct deformities that result from disease, trauma or birth defects.

Cosmetic surgery, any surgery done primarily to improve or change the way one appears, is considered not medically necessary. 

If a specific procedure, treatment, supply, device, or drug is determined to be investigational and/or not medically necessary in accordance with another medical policy, that medical policy governs. 

The Plan will not cover complications or later surgery related in any way to cosmetic procedures/surgeries, even if medically necessary, if caused by an accident, or if done for mental or emotional relief as cosmetic procedures/surgeries are a benefit exclusion. 

Note: In general, these are medical criteria for coverage.  It must be noted that self-funded groups may have different language and the provider should verify contract language.

Women's Health and Cancer Rights Act The Federal Law

The Women’s Health and Cancer Rights Act (WHCRA), signed into law on October 21, 1998, contains protections for patients who elect breast reconstruction in connection with a mastectomy. For plan participants and beneficiaries receiving benefits in connection with a mastectomy, plans offering coverage for a mastectomy must also cover reconstructive surgery and other benefits related to a mastectomy.

The Women’s Health and Cancer Rights Act:

• Applies to group health plans for plan years starting on or after October 21, 1998
• Applies to group health plans, health insurance companies or HMOs, if the plan or coverage provides medical and surgical benefits with respect to a mastectomy
• Requires coverage for reconstructive surgery in a manner determined in consultation with the attending physician and the patient

Under WHCRA, mastectomy benefits must include coverage for:

• Reconstruction of the breast on which the mastectomy was performed
• Surgery and reconstruction of the other breast to produce a symmetrical appearance
• Prostheses and physical complications at all stages of mastectomy, including lymphedemas

DESCRIPTION OF PROCEDURE OR SERVICE:

Coverage eligibility of surgical therapy to treat musculoskeletal abnormalities and abnormalities of the integumentary system are often based on whether the abnormality is considered reconstructive or cosmetic in nature.  Reconstructive surgery is generally provided to restore or improve the way the body works or correct deformities that result from disease, trauma or birth defects.  Cosmetic surgery is provided primarily to improve or change the way one appears.  Reconstructive surgery is a covered benefit while cosmetic surgery is not covered. 

The following general principles describe the issues to be determined in properly administering the contract language. 

1. Eligibility of a service for coverage may be based upon whether a specific benefit addressing cosmetic or reconstructive surgery exists in the contract or upon a specific exemption from an exclusion in the contract for cosmetic or reconstructive surgery or both.
2. Reconstructive surgery is determined based on the following factors:  a) Whether the surgery is primarily indicated to restore or improve the way the body works or to correct deformities. b) Etiology of the defect as resulting from disease, trauma or birth defects.  Therapeutic interventions include but are not limited to surgery, radiation, and chemotherapy.  Cosmetic surgery is usually considered to be those that are primarily to restore or improve appearance and that otherwise do not meet the definition of reconstructive. 
3. Reconstructive surgery occasionally overlaps with the concept of medically necessary.  Surgery intended to correct impairment may also be considered medically necessary and thus eligible for coverage, regardless of the contract language pertaining to reconstructive surgery, unless some other exclusion applies. 
4. A critical point in determining coverage eligibility is the interpretation of the definition of reconstructive surgery particularly in dermatologic conditions. The status/condition of the skin is more difficult to define. Procedures designed to enhance the appearance of the skin are typically considered cosmetic. Some dermatologic conditions may significantly impair the status/condition of the skin due to disease, trauma or birth defects.  There are policies addressing procedures related to some of these procedures.  Some procedures are always considered cosmetic such as ear piercing, neck tucks, face lifts, buttock and thigh lifts, implants to small but normal breasts (except as provided by the Women’s Health and Cancer Rights Act).   In other surgeries, such as blepharoplasty, rhinoplasty, chemical peel and chin implants, it depends on the reason for the surgery. 
5. The definition of reconstructive surgery may also include those services designed to restore the normal appearance of the patient.  Breast reconstruction surgery after a medically necessary mastectomy, or revision of scars related to disease, trauma or birth defects in unexposed areas are common examples. The determination of coverage eligibility typically depends on the etiology of the condition.   

KEY POINTS:

Not applicable 

KEY WORDS:

Cosmetic surgery, cosmetic services, complications of cosmetic surgery, reconstructive surgery, reconstructive services, Women’s Health and Cancer Rights Act, blepharoplasty, dermabrasion, rhinoplasty, chemical peel

APPROVED BY GOVERNING BODIES:

Not applicable

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts: Special benefit consideration may apply. Refer to member’s benefit plan.

Precertification requirements: May be required for inpatient services per member’s contract, please refer to member’s benefit plan.

Predetermination requirements: Performed as a courtesy for providers and members, contact the Plan prior to surgery to find our whether a procedure will be reconstructive or cosmetic. The subscriber and physician must prove that the surgery is reconstructive and not cosmetic. Submitted documentation may include history and physical exams, visual fields measures and photographs before and after surgery as requested per procedure.

REFERENCES:

Not applicable

CODING: 

Not applicable

POLICY HISTORY:

Medical Policy Group, May 2003 (1)

Medical Policy Administration Committee, June 2003

Available for comment July 1-August 14, 2003

Medical Policy Group, February 2007 (3)

Medical Policy Group, February 2010 (1) No benefit changes that would alter the statements on this policy.

Medical Policy Group, February 2012 (1) No benefit changes that would alter the statements on this policy.

Medical Policy Group, February 2014 (1) No benefit changes that would alter the statements on this policy.

Medical Policy Group, February 2016 (1) No benefit changes that would alter the statements on this policy.

Medical Policy Group, August 2018 (7): Clarification to verbiage in Policy Statement- added “as cosmetic procedures/surgeries are a benefit exclusion” to  the complications or surgery related to cosmetic procedures statement. No benefit changes that would alter the intent of Policy Statement. Added Key Words: gender reassignment.

Medical Policy Group, October 2019 (7) No benefit changes that would alter the statements on this policy.

Medical Policy Group, March 2021 (7): Policy Statement updated: added “If a specific procedure, treatment, supply, device, or drug is determined to be investigational and/or not medically necessary in accordance with another medical policy, that medical policy governs.” No benefit changes that would alter intent of Policy Statement.

Medical Policy Group, January 2022 (7) No benefit changes that would alter the statements on this policy.

Medical Policy Group, January 2023 (7): No benefit changes that would alter the statements on this policy. Added Key Word: “WHCRA”.

Medical Policy Group, January 2024 (7) No benefit changes that would alter the statements on this policy. Update to Benefit Application. 

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.