This document describes the cosmetic, reconstructive, and medically necessary uses of a selection of procedures addressing the treatment of abnormalities of the head and neck. 

Note:  Please see the following for additional information:

• ANC.00007 Cosmetic & Reconstructive Services: Skin Related
• MED.00054 Treatment for Obstructive Sleep Apnea in Adults
• SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery
• CG-SURG-18 Septoplasty
• CG-SURG-27 Gender Reassignment Surgery

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant physical functional impairment AND the procedure can be reasonably expected to improve the physical functional impairment. 

Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect.
NOTE: Not all benefit contracts include benefits for reconstructive services as defined by this document. Benefit language supersedes this document. 

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation.  Cosmetic services are often described as those that are primarily intended to preserve or improve appearance. 

A.   Facial Plastic Surgery: (including, but not limited to, mentoplasty with or without implant, submental lipectomy, genioplasty)

Facial plastic surgery is considered medically necessary when required to correct a significant physical functional impairment and the procedure can be reasonably expected to improve the physical functional impairment. Examples of physical functional impairment include procedures required to allow for speech, nutrition, control of secretions, protection of the airway, or corneal protection.

Facial plastic surgery is considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, or treatment of a disease or congenital defect.
Note:The initial restoration may be completed in stages.

Facial plastic surgery is considered cosmetic and not medically necessary when intended to change physical appearance that would be considered within normal human anatomic variation. Examples include, but are not limited to, familial jaw or chin deformities, or weak chin, or to remove excess fat or skin from under the chin.

B.    Otoplasty

Otoplasty is considered medically necessary when performed to surgically correct a physical structure or absence of a physical structure that is causing hearing loss, or intended to facilitate the use of a hearing aid or device when both of the following criteria are met:

• the procedure is reasonably expected to improve the physical functional impairment; and
• an audiogram documents a loss of at least 15 decibels in the affected ear(s).

Otoplasty is considered reconstructive when performed to restore a significantly abnormal external ear or auditory canal related to accidental injury, disease, trauma, or treatment of a disease or congenital defect. Repair of ear lobes only is not considered reconstructive.   

Otoplasty is considered reconstructive when performed to restore the absence of the external ear due to accidental injury, disease, trauma, or the treatment of a disease or congenital defect.

Otoplasty is considered cosmetic and not medically necessary when performed for clefts or other consequences of ear piercing, or protruding ears.

Otoplasty is considered cosmetic and not medically necessary for all other indications.

C.    Rhinophyma

Excision or shaving of the rhinophyma is considered medically necessary when both of the following criteria are met:

• the medical record documentation includes evidence of bleeding or infection; and
• the procedure can be reasonably expected to improve physical functional impairment as a result of bleeding or infection.

Excision or shaving of the rhinophyma is considered cosmetic and not medically necessary when the criteria above have not been met.

D.    Rhinoplasty

Rhinoplasty is considered medically necessary when both of the following criteria are met:

• the medical record documentation includes evidence of the failure of conservative medical therapy for severe airway obstruction from deformities due to disease, structural abnormality, or previous therapeutic process that will not respond to septoplasty alone; and
• the procedure can be reasonably expected to improve the physical functional impairment.

Note: Only the initial restorative repair is medically necessary, unless the procedure is completed in stages with healing periods, then all stages are medically necessary.

Rhinoplasty is considered reconstructive if there is documented evidence (i.e., radiographs or appropriate imaging studies) of nasal fracture resulting in significant variation from normal without physical functional impairment. The intent of the surgery is to correct the deformity caused by the nasal fracture.  

Rhinoplasty to modify the shape or size of the nose is considered cosmetic and not medically necessary  when the criteria above have not been met. 

E.    Rhytidectomy (Face lift)

Rhytidectomy is considered reconstructive when performed for the treatment of significant burns or other significant major facial trauma.

Rhytidectomy is considered cosmetic and not medically necessary when performed for all other indications, including, but not limited to, removal of wrinkles or excess skin or to tighten facial muscles.

F.    Cranial Nerve Procedures  

Transfers, anastomosis or other procedures of the facial nerve or other cranial nerves or their branches are considered medically necessary when required to correct a significant physical functional impairment and the procedure can be reasonably expected to improve the physical functional impairment. Examples of physical functional impairment include, but are not limited to, procedures required to allow for speech, nutrition, control of secretions, protection of the airway, or corneal protection.

Transfers, anastomosis or other procedures of the facial nerve or other cranial nerves or their branches are considered reconstructive when performed for the treatment of congenital or acquired facial palsy resulting in a significantly altered appearance.  

Transfers, anastomosis or other procedures of the facial nerve or other cranial nerves or their branches are considered not medically necessary when the above criteria have not been met.

G.    Ear or Body Piercing

Ear or body piercing is considered cosmetic and not medically necessary when performed for any reason. 

H.  Frown Lines

Removal of frown lines is considered cosmetic and not medically necessary when performed for any reason, including the excision or correction of glabella frown lines or forehead lift (cosmetic foreheadplasty).

I.     Neck Tuck

Neck tucks are considered cosmetic and not medically necessary when performed for any reason. 

Concepts of Medical Necessity, Reconstructive and Cosmetic

The coverage eligibility of medical and surgical therapies to treat head and neck abnormalities is often based on a determination of whether the abnormality is considered medically necessary, reconstructive or cosmetic in nature. In many instances the concept of reconstructive overlaps with the concept of medical necessity. For example, services intended to correct a significant physical functional impairment as a result of trauma will be considered medically necessary and thus eligible for coverage, regardless of the contract language pertaining to reconstructive services, unless some other exclusion applies. Generally, reconstructive is often taken to mean that the service "returns the patient to whole" as a result of a congenital anomaly, disease or other condition including post trauma or post therapy, while cosmetic generally describes improving a physical appearance that would be considered within normal human anatomic variation. Categories of conditions without associated functional impairment that may be included as reconstructive definitions, include or may be due to the following: a) surgery, b) accidental trauma or injury, c) diseases, d) congenital anomalies, e) severe anatomic variants, and f) chemotherapy.

Ear and body piercing is done for cosmetic or aesthetic reasons. Piercing the ears, nose, lip, or any other body part has no acceptable medical use and therefore is not considered medically necessary.

Facial plastic surgery is a general term for any surgery that proposes to alter the appearance of the face. For the purposes of this document the term specifically relates to surgery that is designed to alter the appearance of the lower face including the upper and lower jaw and chin. Surgery for these portions of the face may be considered cosmetic, or may be indicated in instances where severe abnormalities result in functional impairments that affect the ability to eat, swallow, or breathe. These procedures may also be reasonable to correct or restore appearance following traumatic injuries or surgery to treat a medical or surgical condition that result in anatomical changes.

Surgery for frown lines is intended to remove wrinkles that result from the aging process. A "neck tuck" is a surgical procedure to remove excess skin and fat from the neck area under the chin. This area may also be referred to as a double chin. These surgeries are not reconstructive in nature but are performed for cosmetic purposes.  

Osteotomy and osteoplasty are surgical procedures which involve the opening of a bone (osteotomy), or the reconfiguration of a bone (osteoplasty). Such procedures are required when the alignment of a bony structure is misaligned to such a degree that it results in physical functional impairment. These types of surgeries are usually complex and may involve several procedures or steps to accomplish the desired result.

Otoplasty refers to surgical procedures intended to reshape the structure of a misshapen or injured outer ear, or to construct an ear that was absent at birth or as a result of trauma. Such surgery may be considered cosmetic when there is no physical functional impairment or trauma involved, but may be reconstructive or medically necessary in instances where the ear is misshapen enough to interfere with normal hearing, is absent at birth, or has been deformed due to disease or trauma.

Rhinophyma is a condition where the nose becomes enlarged, red in color, and bulb-shaped in appearance. The cause of rhinophyma is unknown, but has been associated with long standing rosacea, a chronic skin rash that is characterized by reddening of the skin on the face. This condition typically affects male Caucasians over 40 years of age, although some cases have been reported in women and younger individuals. Because this condition results in many pits and fissures in the skin, bleeding and infection may develop indicating the need for further medical treatment. In all other circumstances, treatment of rhinophyma is considered cosmetic in nature.

Rhinoplasty, also known as a "nose job," is a surgical procedure intended to alter the shape of the nose. This procedure is primarily intended to alter the shape of air pathways to improve the passage of air while breathing, or to correct structural damage due to disease or trauma. In many cases the shape of the inside of the nose, mainly the septum which separates the nostrils, prevents adequate air passage, impeding proper breathing. In other cases, the shape of the nose may become deformed due to disease or trauma resulting in blocked nasal passages. Rhinoplasty is medically indicated when these conditions exist. When rhinoplasty is performed primarily to alter the external appearance of the nose, the procedure has no medical benefit and is considered not medically necessary.

A rhytidectomy, or "face lift" is a surgical procedure where excess skin is removed from the face and the facial muscles are tightened. This procedure may correct a facial abnormality due to burns or facial palsy resulting in a droopy appearance. In addition, face lifts are used to create a more youthful appearance in individuals concerned with changes due to the aging process. In individuals with facial injuries due to burns or lax facial muscles due to palsy, the use of rhytidectomy may allow the restoration of a normal appearance. Rhytidectomy is considered a cosmetic procedure for individuals with no physical functional impairment, disease, or injury-related facial changes.

Nerve anastomosis or grafting, decompression, and peripheral neuroplasty are some of the surgical procedures performed to correct physical functional impairment that may result from cranial and facial nerve pathology, injury or dysfunction. These procedures are expected to improve the individual's physical functions involving speech, nutrition, control of secretions, corneal protection, or airway protection. These reconstructive surgical procedures are also performed to address an individual's significantly altered appearance in the treatment of congenital or acquired facial palsy.

Genioplasty: a surgical procedure intended to reshape the chin

Mandibular: pertaining to the lower jaw

Maxillary: pertaining to the upper jaw

Mentoplasty: a surgical procedure intended to alter the shape of the chin through the use of various implantable devices to make the chin more prominent

Neck tuck: a surgical procedure intended to correct the appearance of the neck

Osteotomy/Osteoplasty: surgical procedures which involve the opening of a bone (osteotomy), or to reconfigure a bone (osteoplasty)

Otoplasty: a surgical procedure to reshape or rebuild the ear

Palsy: a condition affecting the nerves resulting in the inability to move and relaxed, droopy muscles

Rhinophyma: a condition where a person has a bulbous, enlarged, red nose and puffy cheeks; there may also be thick bumps on the lower half of the nose and the nearby cheek areas

Rhinoplasty: a surgical procedure intended to reshape the nose or repair a broken nose

Rhytidectomy: a surgical procedure intended to adjust the appearance of the face by removing excess skin and tightening the underlying muscles

Septoplasty: a surgical procedure intended to repair the nasal septum, a cartilage and bony structure that separates the two nostrils

Submental lipectomy: a surgical procedure intended to remove excess fat below the chin, commonly referred to as a double chin

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Facial Plastic Surgery
When services may be Medically Necessary when criteria are met: 

When services may be Reconstructive:
For the procedure codes listed above, when criteria for reconstructive services are met without significant physical functional impairment; or when the code describes a procedure indicated in the Position Statement section as reconstructive.

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above, when criteria are not met for medically necessary or reconstructive services, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

Otoplasty
When services may be Medically Necessary when criteria are met: 

When services may be Reconstructive:
For the procedure codes listed above, when criteria for reconstructive services are met without significant physical functional impairment; or when the code describes a procedure indicated in the Position Statement section as reconstructive.

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above, when criteria are not met for medically necessary or reconstructive services, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

When services may also be Reconstructive when criteria are met:

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above, when criteria are not met for reconstructive services, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

Rhinophyma Surgery
When services may be Medically Necessary when criteria are met:

When services are Cosmetic and Not Medically Necessary:
For the procedure code listed above, when criteria are not met for medically necessary services, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

Rhinoplasty
When services may be Medically Necessary when criteria are met:

When services may be Reconstructive:
For the procedure codes listed above, when criteria for reconstructive services are met without significant physical functional impairment; or when the code describes a procedure indicated in the Position Statement section as reconstructive.

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above, when criteria are not met for medically necessary or reconstructive services, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

Rhytidectomy (face lift)
When services may be Reconstructive when criteria are met:

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above, when criteria are not met for reconstructive services, for all other diagnoses not listed, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary. 

Cranial Nerve Procedures
When services may be Medically Necessary when criteria are met:

When services may be Reconstructive:
For the procedure codes listed above, when criteria for reconstructive services are met without significant physical functional impairment; or when the code describes a procedure indicated in the Position Statement section as reconstructive.

When services are Not Medically Necessary:
For the procedure codes listed above, when criteria are not met for medically necessary or reconstructive services, or when the code describes a procedure indicated in the Position Statement section as not medically necessary.

Other Procedures
When services are Cosmetic and Not Medically Necessary:

Peer Reviewed Publications:

1. Ballon A, Landes CA, Zeilhofer HF, et al. The importance of the primary reconstruction of the traumatized anterior maxillary sinus wall. J Craniofac Surg. 2008; 19(2):505-509.
2. Becker DG, Becker SS. Reducing complications in rhinoplasty. Otolaryngol Clin North Am. 2006; 39(3):475-492, viii.
3. Boccieri A, Macro C. Septal considerations in revision rhinoplasty. Facial Plast Surg Clin North Am. 2006; 14(4):357-371, vii.
4. Cakmak O, Buyuklu F. Crushed cartilage grafts for concealing irregularities in rhinoplasty. Arch Facial Plast Surg. 2007; 9(5):352-357.
5. Charalampaki P, Kafadar AM, Grunert P, et al. Vascular decompression of trigeminal and facial nerves in the posterior fossa under endoscope-assisted keyhole conditions. Skull Base. 2008; 18(2):117-128.
6. Ducic Y. Reconstruction of the scalp. Facial Plast Surg Clin North Am. 2009; 17(2):177-187.
7. Higuera S, Lee EI, Cole P, et al. Nasal trauma and the deviated nose. Plast Reconstr Surg. 2007; 120(7 Suppl 2):64S-75S.
8. Howard BK, Rohrich RJ.  Understanding the nasal airway: principles and practice. Plast Reconstr Surg. 2002; 109(3):1128-1134.
9. Rhee JS. Arganbright JM, McMullin BT, Hannley M. Evidence supporting functional rhinoplasty or nasal valve repairs: a 25-year systematic review. Otolaryngol Head Neck Surg. 2008; 139(1):10-20
10. Stucker FJ, Lian T, Sanders K. Management of severe bilateral nasal wall collapse. Am J Rhinol. 2002; 16(5):243-248.
11. Vuyk HD. A review of practical guidelines for the correction of deviated, asymmetric nose. Rhinology. 2000; 38(2):72-78.
12. Yetiser S, Karapinar U. Hypoglossal-facial nerve anastomosis: a meta-analytic study. Ann Otol Rhinol Laryngol. 2007; 116(7):542-549.
13. Yugueros P, Friedland JA. Otoplasty: the experience of 100 consecutive patients. Plast Reconstr Surg. 2001; 108(4):1045-1053.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Society of Plastic Surgeons (ASPS). Practice parameter. Nasal surgery. July 2006. Available at: http://www.plasticsurgery.org/Documents/Medical_Profesionals/Nasal-Surgery-Practice-Parameter.pdf. Accessed on September 30, 2009.
2. American Society of Plastic Surgeons (ASPS). Practice parameter. Ear deformity: Prominent ears. December 2005. Available at: http://www.plasticsurgery.org/Documents/Medical_Profesionals/Ear-Deformity-Practice-Parameter.pdf. Accessed on September 30, 2009.
3. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination for Plastic Surgery to Correct Moon Face. NCD #140.4. Effective May 1, 1989. Available at: http://www.cms.hhs.gov. Accessed on September 30, 2009.