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
• CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift
• CG-SURG-18 Septoplasty
• CG-SURG-27 Gender Reassignment Surgery
• SURG.00096 Surgical and Ablative Treatments for Chronic Headaches

Note:  This document does not address surgical procedures involving the mandible, maxilla (or both) or genioplasty procedures. Please refer to SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery for additional information.

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/certificates 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, submental lipectomy)

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 include, but are not limited to, reconstructive procedures which correct or improve a significant functional impairment of 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 a physical appearance that would be considered within normal human anatomic variation. An example includes, but is not limited to, removal of excess fat or skin from under the chin.

Facial plastic surgery is considered cosmetic and not medically necessary when the medically necessary or reconstructive criteria in this section are not met.

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 intended to restore a significantly abnormal external ear or auditory canal related to accidental injury, disease, trauma, or treatment of a disease or congenital defect.

Otoplasty is considered reconstructive when intended 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 intended to change a physical appearance that would be considered within normal human anatomic variation. Examples include, but are not limited to, repair of ear lobes with clefts or other consequences of ear piercing, or protruding ears.

Otoplasty is considered cosmetic and not medically necessary when the medically necessary or reconstructive criteria in this section are not met.

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 medically necessary criteria in this section are not 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 medically necessary or reconstructive criteria in this section are not met. 

E. Rhytidectomy (Face lift)

Rhytidectomy is considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect. Examples include, but are not limited to, significant burns or other significant major facial trauma.

Rhytidectomy is considered cosmetic and not medically necessary when the reconstructive criteria in this section are not met, including, but not limited to, removal of wrinkles, 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 to correct a significant physical functional impairment and the procedure can be reasonably expected to improve the physical functional impairment. Examples of cranial nerve procedures to correct a physical functional impairment include, but are not limited to, procedures 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 intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect. Examples of significant variation from normal include, but are not limited to, congenital or acquired facial palsy.  

Transfers, anastomosis or other procedures of the facial nerve or other cranial nerves or their branches are considered not medically necessary when the medically necessary or reconstructive criteria in this section are not 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, but not limited to, 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 person 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.

Facial plastic surgery is a general term for any surgery that proposes to alter the appearance of the face. Facial plastic surgery may be considered cosmetic, or may be indicated in instances where severe abnormalities result in functional impairments that affect speech, nutrition, control of secretions, protection of the airway, or corneal protection. Reconstructive surgery to the midface, orbital rims or the forehead may require augmentation or reduction, osteotomy, bone or cartilage grafting, or a combination of these procedures. 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 incompletely formed (i.e. microtia), small, or absent at birth or as a result of trauma. The most severe form of microtia is called atresia, where the individual lacks an external auditory canal. Microtia may be found in congenital conditions such as Goldenhar syndrome, hemifacial microsomia, and Treacher-Collins syndrome. Otoplasty 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 is 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.

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.

Osteotomy/Osteoplasty: A surgical procedures that involves 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 that results in the inability of voluntary movement (motor function) or paralysis, generally partial, of a body area.

Rhinophyma: A condition of the face consisting of 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 (cartilage and bony structure that separates the two nostrils).

Submental lipectomy: A surgical procedure, also referred to as a neck tuck, intended to remove excess fat and skin (i.e. double chin) from the neck below the chin.

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  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.

A.  Facial Plastic Surgery
When services may be Medically Necessary or 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 medically necessary or reconstructive services, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

B.  Otoplasty
When services may be Medically Necessary or 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 medically necessary or reconstructive services, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

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

When services are Cosmetic and Not Medically Necessary:
For the procedure codes 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.

D.  Rhinoplasty
When services may be Medically Necessary or 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 medically necessary or reconstructive services, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary. 

E.  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 medically necessary or reconstructive services, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

F.  Cranial Nerve Procedures
When services may be Medically Necessary or Reconstructive when criteria are met:

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 (Ear piercing, Frown lines, Neck Tuck)
When services are Cosmetic and Not Medically Necessary:

Peer Reviewed Publications:

1. Bagheri SC, Meyer RA, Khan HA, Steed MB. Microsurgical repair of peripheral trigeminal nerve injuries from maxillofacial trauma. J Oral Maxillofac Surg. 2009; 67(9):1791-1799.
2. 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.
3. Becker DG, Becker SS. Reducing complications in rhinoplasty. Otolaryngol Clin North Am. 2006; 39(3):475-492, viii.
4. Boccieri A, Macro C. Septal considerations in revision rhinoplasty. Facial Plast Surg Clin North Am. 2006; 14(4):357-371, vii.
5. Cakmak O, Buyuklu F. Crushed cartilage grafts for concealing irregularities in rhinoplasty. Arch Facial Plast Surg. 2007; 9(5):352-357.
6. 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.
7. Corey CL, Most SP. Treatment of nasal obstruction in the posttraumatic nose. Otolaryngol Clin North Am. 2009; 42(3):567-578.
8. Ducic Y. Reconstruction of the scalp. Facial Plast Surg Clin North Am. 2009; 17(2):177-187.
9. Higuera S, Lee EI, Cole P, et al. Nasal trauma and the deviated nose. Plast Reconstr Surg. 2007; 120(7 Suppl 2):64S-75S.
10. Howard BK, Rohrich RJ. Understanding the nasal airway: principles and practice. Plast Reconstr Surg. 2002; 109(3):1128-1134.
11. Lee J, White WM, Constantinides M. Surgical and nonsurgical treatments of the nasal valves. Otolaryngol Clin North Am. 2009; 42(3):495-511.
12. Mehta RP. Surgical treatment of facial paralysis. Clin Exp Otorhinolaryngol. 2009; 2(1):1-5.
13. Moolenburgh SE, McLennan L, Levendag PC, et al. Nasal reconstruction after malignant tumor resection: an algorithm for treatment. Plast Reconstr Surg. 2010; 126(1):97-105.
14. Moore M, Eccles R. Objective evidence for the efficacy of surgical management of the deviated septum as a treatment for chronic nasal obstruction: a systematic review. Clin Otolaryngol. 2011; 36(2):106-113.
15. 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.
16. Rhee JS, Weaver EM, Park SS, et al. Clinical consensus statement: diagnosis and management of nasal valve compromise. Otolaryngol Head Neck Surg. 2010; 143(1):48-59.
17. Stucker FJ, Lian T, Sanders K. Management of severe bilateral nasal wall collapse. Am J Rhinol. 2002; 16(5):243-248.
18. Vuyk HD. A review of practical guidelines for the correction of deviated, asymmetric nose. Rhinology. 2000; 38(2):72-78.
19. Yetiser S, Karapinar U. Hypoglossal-facial nerve anastomosis: a meta-analytic study. Ann Otol Rhinol Laryngol. 2007; 116(7):542-549.
20. Yugueros P, Friedland JA. Otoplasty: the experience of 100 consecutive patients. Plast Reconstr Surg. 2001; 108(4):1045-1053.
21. Zhang YX, Wang D, Follmar KE, et al. A treatment strategy for postburn neck reconstruction: emphasizing the functional and aesthetic importance of the cervicomental angle. Ann Plast Surg. 2010; 65(6):528-534.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Society of Plastic Surgeons (ASPS). Practice parameters. Available at: http://www.plasticsurgery.org/for-medical-professionals/legislation-and-advocacy/health-policy-resources/evidence-based-guidelinespractice-parameters.html. Accessed on June 18, 2012.
   • Ear Deformity: Prominent Ears. December 2005.
   • Nasal Surgery. July 2006.
2. Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations. Plastic Surgery to Correct Moon Face. NCD #140.4. Effective May 1, 1989. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on June 18, 2012.

1. American Academy of Otolaryngology-Head and Neck Surgeons (AAO-HNS). Available at: http://www.entnet.org/. Accessed on June 18, 2012.
2. American Society for Aesthetic Plastic Surgery (ASAPS). Available at: http://surgery.org. Accessed on June 18, 2012.
3. American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Available at: http://www.aafprs.org/. Accessed on June 18, 2012.

Cranial Nerve
Crouzon Syndrome
Facial Palsy
Frown Lines
Neck Tuck
Otoplasty
Parry-Romberg Syndrome
Piercing
Rhinophyma
Rhinoplasty
Rhytidectomy
Submental Lipectomy
Treacher-Collins Syndrome