This document addresses a variety of surgical procedures of the trunk or groin that may be considered medically necessary, cosmetic or reconstructive in nature.

Note: Please see these documents for related topics:

• CG-SURG-12 Penile Prosthesis Implantation
• CG-SURG-27 Gender Reassignment Surgery
• DRUG.00045 Tesamorelin (Egrifta™)
• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
• SURG.00085 Mastectomy for Gynecomastia
• SURG.00086 Reduction Mammaplasty

Note: For information regarding excision of excess abdominal skin, please see SURG.00048 Panniculectomy and Abdominoplasty.

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 which are primarily intended to preserve or improve appearance.

A. Brachioplasty:

Brachioplasty is considered medically necessary when done in the presence of significant physical functional impairment (for example, redundant or excessive skin is interfering with activities of daily living or causing persistent dermatitis, cellulitis, or skin ulcerations) and impairment persists despite optimal medical management (for example, topical or systemic treatments for infection) and the procedure is reasonably expected to improve that significant physical functional impairment.

Brachioplasty is considered cosmetic and not medically necessary when done in the absence of significant physical functional impairment or when not expected to improve a significant physical functional impairment.

B. Buttock/Thigh Lift:

Buttock or thigh lifts are considered medically necessary when there is a significant physical functional impairment (for example, redundant or excessive skin is interfering with activities of daily living or causing persistent dermatitis, cellulitis, or skin ulcerations) and impairment persists despite optimal medical management (for example, topical or systemic treatments for infection) and the procedure is reasonably expected to improve that significant physical functional impairment.

Buttock and thigh lifts are considered cosmetic and not medically necessary when done in the absence of significant physical functional impairment or when not expected to improve a significant physical functional impairment.

C. Congenital Abnormalities:

Correction of congenital abnormalities of the trunk and groin are considered medically necessary when there is evidence of a significant physical functional impairment and the procedure can be reasonably expected to improve the physical functional impairment.

Correction of congenital abnormalities of the trunk and groin that are a significant variation from normal are considered reconstructive in nature.

In the absence of a significant physical functional impairment or significant variation from normal, correction of congenital abnormalities is considered cosmetic and not medically necessary.

D. Lipectomy/Liposuction:

Lipectomy or liposuction is considered reconstructive when done to address a significant variation from normal directly related to surgical mastectomy.

Note: Please refer to SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures for information regarding the Women's Health and Cancer Rights Act of 1998.

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

Note: Please refer to SURG.00048 Panniculectomy and Abdominoplasty for information regarding lipectomy and liposuction of the abdomen.

E. Pectus Excavatum/Carinatum:

Surgical repair of a significant pectus excavatum with either an open or a minimally invasive approach (Nuss procedure) is considered reconstructive for individuals with a Haller index (pectus severity index) of greater than or equal to 3.2.

Surgical repair of a significant pectus carinatum is considered reconstructive for individuals with a Haller index (pectus severity index) of less than or equal to 2.0.

Surgical repair of pectus excavatum or carinatum is considered cosmetic and not medically necessary when the criteria above have not been met.

Note:

1. For pectus excavatum the Haller index is calculated index using CT measurements of the transverse diameter of the thorax measured between the internal rib margins, divided by the minimal antero-posterior depth as measured from the internal aspect of the sternum to the anterior cortex of the subjacent vertebral body).
2. For pectus carinatum the index is calculated index using CT measurements of the transverse diameter of the thorax measured between the internal rib margins, divided by the antero-posterior depth as measured from the most anterior level of the sternum to the anterior cortex of the subjacent vertebral body).

F. Procedures on the Male or Female Genitalia:

Procedures intended to improve the appearance or enhance the sexual performance of either male or female genitalia, are considered cosmetic and not medically necessary including, but not limited to, the following:

1. Female:
   • labia minora reduction
   • labia major reshaping
   • clitoral reduction
   • hymenoplasty
   • pubic liposuction or lift
2. Male:
   • phalloplasty

Vaginal rejuvenation or vaginal tightening procedures are considered not medically necessary under all circumstances.

Procedures intended to address the sequelae of significant trauma, injury or disease performed on either male or female genitalia, in the absence of a functional impairment, may be considered reconstructive in nature, including, but not limited to, surgical correction of ambiguous genitalia.

Concepts of Medical Necessity, Reconstructive and Cosmetic
The coverage eligibility of medical and surgical therapies to treat musculoskeletal abnormalities is often based on a determination of whether repair of 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.

Brachioplasty, Buttock/Thigh lift
Brachioplasty and buttock or thigh lifts have been proposed as a treatment for individuals with conditions related to excess skin and subcutaneous fat associated with significant physical functional impairment. Conditions such as persistent infection or maceration resistant to conservative therapy that pose a risk to an individual's health may be indications for brachioplasty, buttock lift or thigh lift.

Pectus Excavatum and Carinatum
Validation of the medical necessity of surgical repair of pectus excavatum requires objective documentation of an associated functional impairment that is improved following surgical correction. In many cases, the motivation for surgical correction may be the restoration of a normal appearance. However, some individuals have reported associated cardiorespiratory symptoms such as mild to moderate exercise limitation, respiratory infections or asthmatic symptoms. Nevertheless, the published literature regarding pectus excavatum is dominated by articles focusing on the surgical technique; few articles have published studies that have included results of pre- and postoperative cardiorespiratory function tests. In general, the available literature investigating significant objective functional limitations associated with the presence of pectus excavatum (PE) or significantly improved objective functional outcomes as a result of corrective surgery provides inadequate, controversial or conflicting data, which do not convincingly support surgical repair of PE on functional grounds. Moreover, there is no evidence that the presence of PE limits life expectancy or the ability to perform any sort of occupation.

In a review article, Shamberger concluded that preoperative cardiopulmonary testing in subjects with pectus excavatum revealed a wide range of cardiopulmonary abnormalities, but since studies frequently did not report the degree of severity of the pectus excavatum or define controls, no generalizations could be made (Shamberger, 2000). Morshuis and colleagues (1994a) studied the pulmonary function in 152 subjects with pectus excavatum before and after surgical correction. Pulmonary function was abnormal preoperatively and may have been part of the motivation for surgery. However, multivariate analysis showed that preoperative pulmonary function was not related to age, the severity of the deformity at physical examination, or to pulmonary complaints. At follow-up (mean, 8.1 +/- 3.6 years), the restriction of pulmonary function was increased despite improvement in the symptoms of most subjects and despite a significant increase in the anteroposterior diameter of the chest. Morshuis (1994b) reported on another case series of 35 subjects who underwent pulmonary function tests and exercise testing. Cardiorespiratory symptoms were present in almost all subjects before surgery; these symptoms either diminished or disappeared by one-year post surgery. However, the results of the cardiorespiratory tests did not correlate with the clinical improvement. For example, all measures of pulmonary function decreased after surgery. The authors hypothesize that this decrease is related to postoperative restriction of the chest wall. After operation there was also a significant increase in the maximal oxygen uptake during exercise while the maximal work performance was unchanged.  These findings suggest a less efficient cardiorespiratory function.

Kaguraoka and colleagues (1992) reported on a series of 138 subjects with pectus excavatum, correlating the degree of respiratory improvement with the severity of the deformity in the 22 who were available for postoperative assessment. There was mild respiratory impairment prior to surgery as measured by a mean percent of predicted vital capacity (VC) of 86%. The severity of deformity was inversely related to the VC. Post surgery, the VC increased only slightly. Other respiratory parameters did not change. The authors concluded that surgical correction resulted in adequate cosmetic results but did not importantly influence objective measures of respiratory function.

Peterson (1985) reported on the cardiovascular function of 13 subjects who underwent surgical repair of pectus excavatum. All subjects were symptomatic before surgery and showed a striking improvement post surgery. However, left ventricular ejection fraction and cardiac index, as measured by radionuclide studies at rest and during exercise, were normal both before and after surgery. There was an increase in ventricular volumes, suggesting that some degree of cardiac compression had been relieved by the surgical correction.

The above articles, which are representative of the literature on pectus excavatum, indicate that there is discordance between participants' subjective assessment of improvement and objective measures of cardiorespiratory function. Some have suggested that discordance is due to the fact that improvements in cardiorespiratory function can only be seen during periods of exercise, and thus are not detected during routine pulmonary function tests. Haller and colleagues (2000) studied 15 subjects before and after surgery for pectus excavatum and compared the results to age matched controls. After surgery, individuals exercised longer and had a higher oxygen pulse than before surgery, whereas the non-surgical control group showed no such changes. Subjectively, 66% of subjects undergoing surgery reported improved exercise tolerance. The authors concluded that repair of pectus excavatum improved cardiorespiratory function during vigorous exercise.

In an attempt to explain subjective reports of improved exercise tolerance following surgical repair, a few small studies have demonstrated impairment in some aspects of right ventricular function in the presence of pectus excavatum (PE) with improvement post repair, suggesting that PE causes compression/compromise of the relatively distensible right ventricle. Kowalewski et al. (1999) demonstrated post-operative improvement in right ventricular pressures and stroke volume in a group of 42 subjects with surgically repaired PE. However there was no correlation made with any objective functional impairment, and pre- and post-operative exercise tolerance together with other parameters of cardiac performance (e.g., heart rate, maximal O2 uptake) were not reported. They also found no correlation between the degree of severity of the PI ("pectus index") and degree of pre-operative right ventricular functional impairment or the extent of the changes in right ventricular indices post-operatively.

The Haller index has been used as a measurement of chest deformity in individuals with pectus excavatum for many years. Many studies have used a cut-point of 3.2 to determine the appropriateness of surgery, and this has become the accepted standard for most individuals undergoing pectus repair procedures (Nuss, 1998; Nuss, 2002; Croitoru, 2002).

As with pectus excavatum, the measurement of pectus carinatum is commonly done using the Haller index. Although there is far less published data for this condition when compared to pectus excavatum, it has been widely accepted that a Haller index of 2.0 or less is a reasonable threshold for consideration of surgical correction of pectus carinatum (Fonkalsrud, 2006, 2004, 2002).

Regarding the surgical outcomes of a minimally invasive approach to correction, (i.e., the Nuss procedure), initial results suggested a good to excellent outcome in the majority of individuals among those who have completed the treatment with subsequent removal of the steel bar. (Nuss, 1998; Morshuis, 1994)

Brachioplasty is a surgical procedure used to remove excess fat and skin from the back of the upper arm. This procedure is done primarily to improve an individual's appearance. However, when associated with significant physical functional impairment this procedure may be necessary to protect the individual's health.

Buttock and thigh lifts are surgical procedures used to remove excess fat and skin from the buttocks and thighs. These procedures are primarily intended to enhance the appearance and have no known medical benefits, although these procedures may be necessary when the excessive tissue presents a significant functional impairment despite optimal medical management.

Congenital abnormalities in children include a wide variety of physical abnormalities present at birth. In many cases, the abnormality is not associated with any functional impairment. However, its correction can be considered reconstructive in nature. In most severe cases, immediate surgical care is needed to save a child's life.

Cosmetic surgery is defined as any surgical procedure conducted solely to enhance an individual's appearance. Such surgical procedures have no impact on an individual's physical health.

Liposuction, also known as lipoplasty or suction-assisted lipectomy, is a surgery performed to recontour the individual's body by removing excess fat deposits that have been resistant to reduction by diet or exercise. This procedure has been used successfully on many locations on the body, including the buttocks, thighs, chin and tummy, but does not remove large quantities of fat and is not intended as a weight reduction technique. However, liposuction is also used to address a significant variation from normal in the breast related to surgical mastectomy.

Pectus excavatum is an abnormality of the chest present at birth consisting of a depression in the center of the chest over the sternum. It is caused by excessive growth of the cartilage (connective tissue) joining the ribs to the breastbone, with the result being an inward deformity of the sternum. Although it has been proposed that pectus excavatum can be associated with various cardiopulmonary dysfunctions, this relationship has not been confirmed in the published literature. Until recently surgical correction of pectus excavatum involved the resection of the involved costal cartilages and osteotomy of the sternum with placement of a metal bar behind the sternum. The metal bar may be removed in one to two years. In the past several years, a minimally invasive approach has been developed that involves the placement of a convex steel bar beneath the sternum through small bilateral thoracic incisions. The bar may be removed after two years when remolding of the cartilage is complete. This procedure, which may be referred to as the Nuss procedure or MIRPE (minimally invasive repair of pectus excavatum) does not require cartilage resection or sternal osteotomy. The degree of deformity in individuals with this condition is commonly measured using the Haller index. The index is calculated using chest dimension measurements obtained with computed tomography (also known as a CT scan). A Haller Index of at least 3.2 is generally recognized to indicate a pectus excavatum of sufficient severity to consider surgical repair.

Pectus carinatum describes a condition where the breastbone protrudes out from the chest, often described as giving the person a bird-like appearance. Pectus carinatum may occur as a solitary abnormality or in association with other genetic disorders or syndromes. Although it has been proposed that pectus carinatum can be associated with various cardiopulmonary dysfunctions, this relationship has not been confirmed in the published literature. As with pectus excavatum, the degree of deformity is measured using the Haller index. A Haller Index of 2.0 or less is generally recognized to indicate a pectus carinatum of sufficient severity to consider surgical repair.

A wide variety of procedures have been proposed to alter the appearance, size, or function of the external and internal female genitalia. Surgical procedures to alter the size or shape of the labia or clitoris, restore the hymen, and other such measures do not provide any physical health benefits.

The labia minora is part of the external structure of the vagina. In some individuals the labia minora may be enlarged or asymmetrical leading to mild discomfort with wearing certain clothing or during some activities. Reconstructive surgical procedures have been proposed to reduce enlarged labia minora. These procedures have not been well studied in the medical literature and the possible risks they present have not been adequately assessed in relation to the potential benefits.

Phalloplasty is a surgical procedure to reconstruct or enlarge the penis. Reconstruction may be required in cases of traumatic injury or loss due to disease. Enlargement may be desired in cases of abnormally small penis size.

Functional impairment: Limits on normal physical functioning that may include, but are not limited to, problems with ambulation, mobilization, communication, respiration, eating, swallowing, vision, facial expression, skin integrity, distortion of nearby body parts, or obstruction of an orifice. The cause of the physical functional impairment can be due to pain, structural, congenital or other means. Physical functional impairment excludes social, emotional, and psychological impairments or potential impairments.

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.  Brachioplasty
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 medically necessary criteria are not met.

B.  Buttock/thigh lift
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 medically necessary criteria are not met, and for the following procedure codes:

D.  Lipectomy, liposuction
When services may be Reconstructive when criteria are met, specified as related to surgical mastectomy:
Note: for criteria for breast reconstructive procedures, see SURG.00023 

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above when reconstructive criteria are not met and for all other diagnoses not listed. 

When services are also Cosmetic and Not Medically Necessary: 

When services may be Medically Necessary, Reconstructive or Cosmetic and Not Medically Necessary: 

E.  Repair of Pectus Excavatum or Pectus Carinatum
When services may be Reconstructive when criteria are met: 

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above, when reconstructive criteria are not met.

F.  Procedures on male or female genitalia
When services may be Cosmetic and Not Medically Necessary or Reconstructive based on criteria: 

Peer-Reviewed Publications:

1. Bawazir OA, Montgomery M, Harder J, Sigalet DL. Midterm evaluation of cardiopulmonary effects of closed repair for pectus excavatum. J Pediatr Surg. 2005; 40(5):863-867.
2. Coln E, Carrasco J, Coln D. Demonstrating relief of cardiac compression with the Nuss minimally invasive repair for pectus excavatum. J Pediatr Surg. 2006; 41(4):683-686.
3. Croitoru DP, Kelly RE Jr, Goretsky MJ, et al.  Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients. J Pediatr Surg. 2002; 37(3):437-445.
4. Daunt SW, Cohen JH, Miller SF. Age-related normal ranges for the Haller index in children. Pediatr Radiol. 2004; 34(4):326-330.
5. Fonkalsrud EW, Anselmo DM. Less extensive techniques for repair of pectus carinatum: the undertreated chest deformity.J Am Coll Surg. 2004; 198(6):898-905.
6. Fonkalsrud EW, DeUgarte D, Choi E. Repair of pectus excavatum and carinatum deformities in 116 adults. Ann Surg. 2002; 236(3):304-12; discussion 312-314.
7. Fonkalsrud EW, Mendoza J. Open repair of pectus excavatum and carinatum deformities with minimal cartilage resection. Am J Surg. 2006; 191(6):779-784.
8. Haller JA, Loughlin GM. Cardiorespiratory function is significantly improved following corrective surgery for severe pectus excavatum. Proposed treatment guidelines. J Cardiovasc Surg. 2000; 41:125-130.
9. Hebra A, Swoveland B, Egbert M, et al. Outcome analysis of minimally invasive repair of pectus excavatum. Review of 251 cases. J Pediatr Surg. 2000; 35:252-257.
10. Huddleston CB. Pectus excavatum. Semin Thorac Cardiovasc Surg. 2004; 16(3):225-232.
11. Kaguraoka H, Ohnuki T, Itaoka T, et al. Degree of severity of pectus excavatum and pulmonary function in preoperative and postoperative periods. J Thoracic Cardiovasc Surg. 1992; 104:483-488.
12. Kowalewski J, Brocki M, Dryjanski T, et al. Pectus excavatum: increase of right ventricular systolic, diastolic, and stroke volumes after surgical repair. J Thorac Cardiovasc Surg. 1999; 118(1):87-92.
13. Lawson ML, Barnes-Eley M, Burke BL, et al. Reliability of a standardized protocol to calculate cross-sectional chest area and severity indices to evaluate pectus excavatum. J Pediatr Surg. 2006; 41(7):1219-1225.
14. Lawson ML, Mellins RB, Tabangin M, et al. Impact of pectus excavatum on pulmonary function before and after repair with the Nuss procedure. J Pediatr Surg. 2005; 40(1):174-180.
15. Malek MH, Berger DE, Housh TJ, et al. Cardiovascular function following surgical repair of pectus excavatum: a meta analysis. Chest. 2006; 130(2):506-516.
16. Morshuis WJ, et al. Exercise cardiorespiratory function before and one year after operation for pectus excavatum. J Thorac Cardiovasc Surg. 1994a; 107(6):1403-1409.
17. Morshuis W, Folgering H, Barentsz J, et al. Pulmonary function before surgery for pectus excavatum and at long-term follow up. Chest 1994b; 105:1646-1652.
18. Nuss D, Croitoru DP, Kelly RE Jr, et al. Review and discussion of the complications of minimally invasive pectus excavatum repair. Eur J Pediatr Surg. 2002; 12(4):230-234.
19. Nuss D, Kelly RE, Croitoru DP, Katz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg. 1998; 33:545-552.
20. Peterson RJ, Young WG, Godwin JD, et al. Noninvasive assessment of exercise cardiac function before and after pectus excavatum repair. J Thorac Cardiovasc Surg. 1985; 90:251-260.
21. Schalamon J, Pokall S, Windhaber J, Hoellwarth ME. Minimally invasive correction of pectus excavatum in adult patients. J Thorac Cardiovasc Surg. 2006; 132(3):524-529.
22. Shamberger RC.  Cardiopulmonary effects of anterior chest wall deformities. Chest Surg Clin N Am. 2000; 10(2):245-252.
23. Sigalet DL, Montgomery M, Harder J. Cardiopulmonary effects of closed repair of pectus excavatum. J Pediatr Surg. 2003; 38(3):380-385.
24. Sigalet DL, Montgomery M, Harder J, et al. Long term cardiopulmonary effects of closed repair of pectus excavatum. Pediatr Surg Int. 2007; 23(5):493-497.
25. Wynn SR, Riscoll DJ, Ostrum NK, et al.  Exercise cardiorespiratory function in adolescents with pectus excavatum. Observations before and after operation.  J Thorac Cardiovasc Surg. 1990; 9:41-47.

1. American Society for Aesthetic Plastic Surgery. Available at: http://www.surgery.org/. Accessed June 18, 2012.
2. American Academy of Facial Plastic and Reconstructive Surgery. Available at: http://www.aafprs.org/. Accessed June 18, 2012.
3. American Society of Plastic Surgeons. Available at: http://www.plasticsurgery.org. Accessed June 18, 2012.

Brachioplasty
Buttock
Congenital Abnormalities
Labia Minora
Lipectomy
Liposuction
Pectus Carinatum
Pectus Excavatum
Phalloplasty
Sex Reassignment
Thigh