Medical Policy



Subject: Cosmetic and Reconstructive Services of the Head and Neck
Document #: ANC.00008 Current Effective Date:    06/28/2017
Status: Reviewed Last Review Date:    05/04/2017

Description/Scope

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 documents for additional information:

Note:  

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.

Position Statement

A.  Facial Plastic Surgery:

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.

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:

  1. the procedure is reasonably expected to improve the physical functional impairment; and
  2. 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:

  1. the medical record documentation includes evidence of bleeding or infection; and
  2. 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 or Rhinoseptoplasty (procedure which combines both rhinoplasty and septoplasty)

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

  1. 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
  2. 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.

Note: Rhinoseptoplasty is considered medically necessary when the criteria above for rhinoplasty are met and medically necessary criteria in CG-SURG-18 Septoplasty are also met.

Rhinoplasty is considered reconstructive if there is documented evidence (that is, 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.  

Rhinoseptoplasty is considered reconstructive if there is documented evidence (that is, radiographs or appropriate imaging studies) of nasal and septal 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 and septal fracture.

Rhinoplasty or rhinoseptoplasty 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 (Submental Lipectomy)

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

Rationale

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.

Background/Overview

Facial plastic surgery is a general term for any surgery performed for the purpose of altering the appearance of the face. Facial plastic surgery may be considered cosmetic, or may be considered medically necessary in those 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 a previous surgery done to treat a medical or surgical condition that resulted in anatomical changes. Other procedures are not done to correct a functional impairment. Surgery for frown lines is intended to remove wrinkles that result from the aging process. A "neck tuck", also known as a neck lift, lower rhytidectomy or submental lipectomy, 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 surgeries are usually complex and may involve several procedures or stages 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 is incompletely formed (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 is 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 numerous 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, septoplasty, and rhinoseptoplasty (or septorhinoplasty) are procedures that involve distinct surgical techniques. When rhinoplasty is performed to alter the shape (contour) or enhance the external appearance of the nose (that is, a "nose job"), the procedure has no medical benefit and is considered cosmetic and not medically necessary. Rhinoplasty may be performed to alter the shape of the nose to improve the passage of air while breathing (from blocked nasal passages or severe nasal obstruction), or to correct structural damage due to disease or trauma (for example, to repair a nasal fracture) without involvement of the underlying nasal septa. Rhinoplasty is medically indicated when these conditions exist. Septoplasty, usually performed under local or general anesthesia, is a surgical procedure to correct nasal septum defects or deformities by alteration, splinting, or partial removal of obstructing structures (Note: The indications for septoplasty alone are not addressed in this document). Septoplasty is an internal procedure which does not affect the outward appearance of the nose, is usually performed to improve breathing, but may also be performed to assist in the management of polyps, tumors or epistaxis. Rhinoseptoplasty, involving both rhinoplasty and septoplasty, is a more extensive surgical procedure combining repairs to the external nasal pyramid or skeleton with repairs of the nasal septa to correct a physical functional impairment involving both structures. Rhinoseptoplasty may also be performed as a reconstructive procedure to correct a nasal and septal 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 and septal fracture.

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.

Definitions

Osteotomy/Osteoplasty: A surgical procedure 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.

Rhinoseptoplasty: A surgical procedure, also referred to as a septorhinoplasty, performed on the nose and the nasal septum (cartilage and bony structure that separates the two nostrils).

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.

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

Coding

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.

A.  Facial Plastic Surgery
When services may be Medically Necessary or Reconstructive when criteria are met:

CPT  
21083 Impression and custom preparation; palatal lift prosthesis
21087 Impression and custom preparation; nasal prosthesis
21137-21139 Reduction forehead [includes codes 21137, 21138, 21139]
21159-21160 Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts)
21172 Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts); without LeFort I
21175 Reconstruction, bifrontal, superiorlateral orbital rims and lower forehead, advancement or alteration (e.g., plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts)
21179-21180 Reconstruction, entire or majority of forehead and/or supraorbital rims
21182-21184 Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra-and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts) [includes codes 21182, 21183, 21184]
21210 Graft, bone; nasal; maxillary or malar areas (includes obtaining grafts)
21230 Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)
21235 Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)
21255 Reconstruction zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)
21256 Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia)
21270 Malar augmentation, prosthetic material
21275 Secondary revision of orbitocraniofacial reconstruction
   
ICD-10 Procedure  
0NU107Z-0NU20KZ Supplement frontal bone, open approach; [right or left with autologous tissue, synthetic or nonautologous tissue substitute; includes codes 0NU107Z, 0NU10JZ, 0NU10KZ, 0NU207Z, 0NU20JZ, 0NU20KZ]
0NUM07Z-0NUN0KZ Supplement zygomatic bone, open approach; [right or left with autologous tissue, synthetic or nonautologous tissue substitute; includes codes 0NUM07Z, 0NUM0JZ, 0NUM0KZ, 0NUN07Z, 0NUN0JZ, 0NUN0KZ]
0NUP07Z-0NUQ0KZ Supplement orbit, open approach [right or left with autologous tissue, synthetic or nonautologous tissue substitute; includes codes 0NUP07Z, 0NUP0JZ, 0NUP0KZ, 0NUQ07Z, 0NUQ0JZ, 0NUQ0KZ]
0WU207Z-0WU20KZ Supplement face, open approach [with autologous tissue, synthetic or nonautologous tissue substitute; includes codes 0WU207Z, 0WU20JZ, 0WU20KZ]
   
ICD-10 Diagnosis  
  All diagnoses

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:

CPT  
69300 Otoplasty, protruding ear, with or without size reduction
69399 Unlisted procedure, external ear [when specified as other otoplasty]
   
ICD-10 Procedure  
09S00ZZ-09S2XZZ Reposition external ear [right, left or bilateral, by approach; includes codes 09S00ZZ, 09S04ZZ, 09S0XZZ, 09S10ZZ, 09S14ZZ, 09S1XZZ, 09S20ZZ, 09S24ZZ, 09S2XZZ]
09U007Z-09U2X7Z Supplement external ear with autologous tissue substitute [right, left or bilateral, by approach; includes codes 09U007Z, 09U0X7Z, 09U107Z, 09U1X7Z, 09U207Z, 09U2X7Z]
09U00JZ-09U2XJZ Supplement external ear with synthetic substitute [right, left or bilateral, by approach; includes codes 09U00JZ, 09U0XJZ, 09U10JZ, 09U1XJZ, 09U20JZ, 09U2XJZ]
09U00KZ-09U2XKZ Supplement external ear with nonautologous tissue substitute [right, left or bilateral, by approach; includes codes 09U00KZ, 09U0XKZ, 09U10KZ, 09U1XKZ, 09U20KZ, 09U2XKZ]
0HN2XZZ-0HN3XZZ Release ear skin, external approach [right or left; includes codes 0HN2XZZ, 0HN3XZZ]
090007Z-0902X7Z Alteration of external ear with autologous tissue substitute [right, left or bilateral, by approach; includes codes 090007Z, 090037Z, 090047Z, 0900X7Z, 090107Z, 090137Z, 090147Z, 0901X7Z, 090207Z, 090237Z, 090247Z, 0902X7Z]
09000JZ-0902XJZ Alteration of external ear with synthetic substitute [right, left or bilateral, by approach; includes codes 09000JZ, 09003JZ, 09004JZ, 0900XJZ, 09010JZ, 09013JZ, 09014JZ, 0901XJZ, 09020JZ, 09023JZ, 09024JZ, 0902XJZ]
09000KZ-0902XKZ Alteration of external ear with nonautologous tissue substitute [right, left or bilateral, by approach; includes codes 09000KZ, 09003KZ, 09004KZ, 0900XKZ, 09010KZ, 09013KZ, 09014KZ, 0901XKZ, 09020KZ, 09023KZ, 09024KZ, 0902XKZ]
09000ZZ-0902XZZ Alteration of external ear [right, left or bilateral, by approach; includes codes 09000ZZ, 09003ZZ, 09004ZZ, 0900XZZ, 09010ZZ, 09013ZZ, 09014ZZ, 0901XZZ, 09020ZZ, 09023ZZ, 09024ZZ, 0902XZZ]
   
ICD-10 Diagnosis  
  All diagnoses

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:

CPT  
30120 Excision or surgical planing of skin of nose for rhinophyma
   
ICD-10 Procedure  
0HB1XZZ Excision of face skin, external approach
   
ICD-10 Diagnosis  
L71.1 Rhinophyma

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 or Rhinoseptoplasty
When services may be Medically Necessary or Reconstructive when criteria are met:

CPT  
30400-30420 Rhinoplasty, primary [includes codes 30400, 30410, 30420]
30430-30450 Rhinoplasty, secondary [includes codes 30430, 30435, 30450]
   
ICD-10 Procedure  
09UK07Z-09UKX7Z Supplement nose with autologous tissue substitute [by approach; includes codes 09UK07Z, 09UKX7Z]
09UK0JZ-09UKXJZ Supplement nose with synthetic substitute [by approach; includes codes 09UK0JZ, 09UKXJZ]
09UK0KZ-09UKXKZ Supplement nose with nonautologous tissue substitute [by approach; includes codes 09UK0KZ, 09UKXKZ]
0NUB07Z Supplement nasal bone with autologous tissue substitute, open approach
0NUB0JZ Supplement nasal bone with synthetic substitute, open approach
0NUB0KZ Supplement nasal bone with nonautologous tissue substitute, open approach
090K07Z-090KX7Z Alteration of nose with autologous tissue substitute [by approach; includes codes 090K07Z, 090K37Z, 090K47Z, 090KX7Z]
090K0JZ-090KXJZ Alteration of nose with synthetic substitute [by approach; includes codes 090K0JZ, 090K3JZ, 090K4JZ, 090KXJZ]
090K0KZ-090KXKZ Alteration of nose with nonautologous tissue substitute [by approach; includes codes 090K0KZ, 090K3KZ, 090K4KZ, 090KXKZ]
090K0ZZ-090KXZZ Alteration of nose [by approach; includes codes 090K0ZZ, 090K3ZZ, 090K4ZZ, 090KXZZ]
   
ICD-10 Diagnosis  
  All diagnoses

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:

CPT  
15824 Rhytidectomy; forehead
15828 Rhytidectomy, cheek, chin, and neck
   
ICD-10 Procedure  
0JD00ZZ Extraction of scalp subcutaneous tissue and fascia, open approach
0JD03ZZ Extraction of scalp subcutaneous tissue and fascia, percutaneous approach
0JD10ZZ Extraction of face subcutaneous tissue and fascia, open approach
0JD13ZZ Extraction of face subcutaneous tissue and fascia, percutaneous approach
0J010ZZ Alteration of face subcutaneous tissue and fascia, open approach
0J013ZZ Alteration of face subcutaneous tissue and fascia, percutaneous approach
0W020ZZ Alteration of face, open approach
0W023ZZ Alteration of face, percutaneous approach
   
ICD-10 Diagnosis  
  All diagnoses

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:

CPT  
15840-15845 Graft for facial nerve paralysis [includes codes 15840, 15841, 15842, 15845]
64716 Neuroplasty and/or transposition; cranial nerve
64732-64742 Transection or avulsion (nerves of face) [includes codes 64732, 64734, 64736, 64738, 64740, 64742]
64864-64865 Suture of facial nerve [includes codes 64864, 64865]
64866-64870 Anastomosis (facial nerves) [includes codes 64866, 64868, 64870]
69955 Total facial nerve decompression and/or repair (may include graft)
   
ICD-10 Procedure  
00NH0ZZ-00NH4ZZ Release oculomotor nerve [by approach; includes codes 00NH0ZZ, 00NH3ZZ, 00NH4ZZ]
00NJ0ZZ-00NJ4ZZ Release trochlear nerve [by approach; includes codes 00NJ0ZZ, 00NJ3ZZ, 00NJ4ZZ]
00NK0ZZ-00NK4ZZ Release trigeminal nerve [by approach; includes codes 00NK0ZZ, 00NK3ZZ, 00NK4ZZ]
00NL0ZZ-00NL4ZZ Release abducens nerve [by approach; includes codes 00NL0ZZ, 00NL3ZZ, 00NL4ZZ]
00NM0ZZ-00NM4ZZ Release facial nerve [by approach; includes codes 00NM0ZZ, 00NM3ZZ, 00NM4ZZ]
00QH0ZZ-00QH4ZZ Repair oculomotor nerve [by approach; includes codes 00QH0ZZ, 00QH3ZZ, 00QH4ZZ]
00QJ0ZZ-00QJ4ZZ Repair trochlear nerve [by approach; includes codes 00QJ0ZZ, 00QJ3ZZ, 00QJ4ZZ]
00QK0ZZ-00QK4ZZ Repair trigeminal nerve [by approach; includes codes 00QK0ZZ, 00QK3ZZ, 00QK4ZZ]
00QL0ZZ-00QL4ZZ Repair abducens nerve [by approach; includes codes 00QL0ZZ, 00QL3ZZ, 00QL4ZZ]
00QM0ZZ-00QM4ZZ Repair facial nerve [by approach; includes codes 00QM0ZZ, 00QM3ZZ, 00QM4ZZ]
00SH0ZZ-00SH4ZZ Reposition oculomotor nerve [by approach; includes codes 00SH0ZZ, 00SH3ZZ, 00SH4ZZ]
00SJ0ZZ-00SJ4ZZ Reposition trochlear nerve [by approach; includes codes 00SJ0ZZ, 00SJ3ZZ, 00SJ4ZZ]
00SK0ZZ-00SK4ZZ Reposition trigeminal nerve [by approach; includes codes 00SK0ZZ, 00SK3ZZ, 00SK4ZZ]
00SL0ZZ-00SL4ZZ Reposition abducens nerve [by approach; includes codes 00SL0ZZ, 00SL3ZZ, 00SL4ZZ]
00SM0ZZ-00SM4ZZ Reposition facial nerve [by approach; includes codes 00SM0ZZ, 00SM3ZZ, 00SM4ZZ]
00XF0ZH-00XF4ZM Transfer olfactory nerve [by destination and approach; includes codes 00XF0ZH, 00XF0ZJ, 00XF0ZK, 00XF0ZL, 00XF0ZM, 00XF4ZH, 00XF4ZJ, 00XF4ZK, 00XF4ZL, 00XF4ZM]
00XG0ZH-00XG4ZM Transfer optic nerve [by destination and approach; includes codes 00XG0ZH, 00XG0ZJ, 00XG0ZK, 00XG0ZL, 00XG0ZM, 00XG4ZH, 00XG4ZJ, 00XG4ZK, 00XG4ZL, 00XG4ZM]
00XH0ZH-00XH4ZM Transfer oculomotor nerve [by destination and approach; includes codes 00XH0ZH, 00XH0ZJ, 00XH0ZK, 00XH0ZL, 00XH0ZM, 00XH4ZH, 00XH4ZJ, 00XH4ZK, 00XH4ZL, 00XH4ZM]
00XJ0ZH-00XJ4ZM Transfer trochlear nerve [by destination and approach; includes codes 00XJ0ZH, 00XJ0ZJ, 00XJ0ZK, 00XJ0ZL, 00XJ0ZM, 00XJ4ZH, 00XJ4ZJ, 00XJ4ZK, 00XJ4ZL, 00XJ4ZM]
00XK0ZH-00XK4ZM Transfer trigeminal nerve [by destination and approach; includes codes 00XK0ZH, 00XK0ZJ, 00XK0ZK, 00XK0ZL, 00XK0ZM, 00XK4ZH, 00XK4ZJ, 00XK4ZK, 00XK4ZL, 00XK4ZM]
00XL0ZH-00XL4ZM Transfer abducens nerve [by destination and approach; includes codes 00XL0ZH, 00XL0ZJ, 00XL0ZK, 00XL0ZL, 00XL0ZM, 00XL4ZH, 00XL4ZJ, 00XL4ZK, 00XL4ZL, 00XL4ZM]
00XM0ZH-00XM4ZM Transfer facial nerve [by destination and approach; includes codes 00XM0ZH, 00XM0ZJ, 00XM0ZK, 00XM0ZL, 00XM0ZM, 00XM4ZH, 00XM4ZJ, 00XM4ZK, 00XM4ZL, 00XM4ZM]
00XN0ZH-00XN4ZM Transfer acoustic nerve [by cranial nerve destination and approach; includes codes 00XN0ZH, 00XN0ZJ, 00XN0ZK, 00XN0ZL, 00XN0ZM, 00XN4ZH, 00XN4ZJ, 00XN4ZK, 00XN4ZL, 00XN4ZM]
00XP0ZH-00XP4ZM Transfer glossopharyngeal nerve [by cranial nerve destination and approach; includes codes 00XP0ZH, 00XP0ZJ, 00XP0ZK, 00XP0ZL, 00XP0ZM, 00XP4ZH, 00XP4ZJ, 00XP4ZK, 00XP4ZL, 00XP4ZM]
00XQ0ZH-00XQ4ZM Transfer vagus nerve [by cranial nerve destination and approach; includes codes 00XQ0ZH, 00XQ0ZJ, 00XQ0ZK, 00XQ0ZL, 00XQ0ZM, 00XQ4ZH, 00XQ4ZJ, 00XQ4ZK, 00XQ4ZL, 00XQ4ZM]
00XR0ZH-00XR4ZM Transfer accessory nerve [by cranial nerve destination and approach; includes codes 00XR0ZH, 00XR0ZJ, 00XR0ZK, 00XR0ZL, 00XR0ZM, 00XR4ZH, 00XR4ZJ, 00XR4ZK, 00XR4ZL, 00XR4ZM]
00XS0ZH-00XS4ZM Transfer hypoglossal nerve [by cranial nerve destination and approach; includes codes 00XS0ZH, 00XS0ZJ, 00XS0ZK, 00XS0ZL, 00XS0ZM, 00XS4ZH, 00XS4ZJ, 00XS4ZK, 00XS4ZL, 00XS4ZM]
   
ICD-10 Diagnosis  
  All diagnoses

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.

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

CPT  
15819 Cervicoplasty
15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)
15826 Rhytidectomy; glabellar frown lines
15829 Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap
15838 Excision, excessive skin and subcutaneous tissue (including lipectomy); submental fat pad
15876 Suction assisted lipectomy; head and neck
69090 Ear piercing
   
ICD-10 Procedure  
0JD40ZZ Extraction of anterior neck subcutaneous tissue and fascia, open approach
0JD43ZZ Extraction of anterior neck subcutaneous tissue and fascia, percutaneous approach
0JD50ZZ Extraction of posterior neck subcutaneous tissue and fascia, open approach
0JD53ZZ Extraction of posterior neck subcutaneous tissue and fascia, percutaneous approach
0W060ZZ Alteration of neck, open approach
0W063ZZ Alteration of neck, percutaneous approach
8E0HXY9 Piercing of integumentary system and breast
   
ICD-10 Diagnosis  
  All diagnoses
   
References

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. Funamura JL, Tollefson TT. Congenital Anomalies of the Nose. Facial Plast Surg. 2016; 32(2):133-1341.
  10. Higuera S, Lee EI, Cole P, et al. Nasal trauma and the deviated nose. Plast Reconstr Surg. 2007; 120(7 Suppl 2):64S-75S.
  11. Howard BK, Rohrich RJ. Understanding the nasal airway: principles and practice. Plast Reconstr Surg. 2002; 109(3):1128-1134.
  12. Kim JH, Lee JW, Park CH. Cosmetic rhinoseptoplasty in acute nasal bone fracture. Otolaryngol Head Neck Surg. 2013; 149(2):212-218.
  13. Lee J, White WM, Constantinides M. Surgical and nonsurgical treatments of the nasal valves. Otolaryngol Clin North Am. 2009; 42(3):495-511.
  14. Mehta RP. Surgical treatment of facial paralysis. Clin Exp Otorhinolaryngol. 2009; 2(1):1-5.
  15. Miller LE, Miller VM. Safety and effectiveness of microvascular decompression for treatment of hemifacial spasm: a systematic review. Br J Neurosurg. 2012; 26(4):438-444.
  16. 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.
  17. 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.
  18. Pluijmers BI, Caron CJ, Dunaway DJ, et al. Mandibular reconstruction in the growing patient with unilateral craniofacial microsomia: a systematic review. Int J Oral Maxillofac Surg. 2014; 43(3):286-295.
  19. 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.
  20. 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.
  21. Ribeiro JS, da Silva GS. Technical advances in the correction of septal perforation associated with closed rhinoplasty. Arch Facial Plast Surg. 2007; 9(5):321-327.
  22. Saltaji H, Altalibi M, Major MP, et al. Le Fort III distraction osteogenesis versus conventional Le Fort III osteotomy in correction of syndromic midfacial hypoplasia: a systematic review. J Oral Maxillofac Surg. 2014; 72(5):959-972.
  23. Serowka KL, Saedi N, Dover JS, Zachary CB. Fractionated ablative carbon dioxide laser for the treatment of rhinophyma. Lasers Surg Med. 2014; 46(1):8-12.
  24. Stucker FJ, Lian T, Sanders K. Management of severe bilateral nasal wall collapse. Am J Rhinol. 2002; 16(5):243-248.
  25. Vuyk HD. A review of practical guidelines for the correction of deviated, asymmetric nose. Rhinology. 2000; 38(2):72-78.
  26. Yetiser S, Karapinar U. Hypoglossal-facial nerve anastomosis: a meta-analytic study. Ann Otol Rhinol Laryngol. 2007; 116(7):542-549.
  27. Yugueros P, Friedland JA. Otoplasty: the experience of 100 consecutive patients. Plast Reconstr Surg. 2001; 108(4):1045-1053.
  28. 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 April 8, 2017.
    • Ear Deformity: Prominent Ears. December 2005. Reaffirmed 2015.
  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 April 8, 2017.
Websites for Additional Information
  1. American Academy of Otolaryngology-Head and Neck Surgeons (AAO-HNS). Available at: http://www.entnet.org/. Accessed on April 8, 2017.
  2. American Academy of Facial Plastic and Reconstructive Surgery, Inc. (AAFPRS). Available at: http://www.aafprs.org/. Accessed on April 8, 2017.
  3. U.S. National Library of Medicine Medline Plus. Head and face reconstruction. Reviewed April 14, 2015. Available at: https://www.nlm.nih.gov/medlineplus/ency/article/002980.htm . Accessed on April 8, 2017.
Index

Crouzon Syndrome
Goldenhar Syndrome
Parry-Romberg Syndrome
Treacher-Collins Syndrome

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Document History
Status Date Action
Reviewed 05/04/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References and Websites sections. Updated formatting in Position Statement section.
Revised 05/05/2016 MPTAC review. Moved term submental lipectomy to neck tuck within position statement. Updated Description, Background/Overview, References and Websites for Additional Information sections. Removed ICD-9 codes from Coding section.
Reviewed 05/07/2015 MPTAC review. Updated References and Websites for Additional Information sections.
Revised 05/15/2014 MPTAC review. Added a reconstructive statement for rhinoseptoplasty, rhinoseptoplasty to the cosmetic and not medically necessary statement (when criteria are not met), and a Note cross-referencing to CG-SURG-18 (Note: Rhinoseptoplasty is considered medically necessary when the criteria above for rhinoplasty are met and medically necessary criteria in CG-SURG-18 Septoplasty are also met). Updated Description, Background/Overview, Definitions, and References sections.
Reviewed 08/08/2013 MPTAC review. Minor format and spacing changes. Updated References, Websites for Additional Information, and Index sections.
Revised 08/09/2012 MPTAC review. Revised section title and cosmetic and not medically necessary statement related to: A. Facial Plastic Surgery: (including, but not limited to, submental lipectomy); clarified reconstructive and cosmetic and not medically necessary statements: B. Otoplasty. Updated Description (added Note with cross-reference to SURG.00049 Mandibular/Maxillary (Orthognathic) Surgery), Background, Definitions, Coding, References and Websites for Additional Information.
Revised 11/17/2011 MPTAC review. Clarified Position Statements for specific indications. Added a cosmetic and not medically necessary statement to the section: Facial Plastic Surgery. Updated References, Websites for Additional Information, and Index.
Reviewed 11/18/2010 MPTAC review. Reordered text and updated Background/Overview. Reformatted Definitions. Updated References and Index.
Reviewed 11/19/2009 MPTAC review. Clarified and reformatted Position Statements. Updated References.
Reviewed 11/20/2008 MPTAC review. Background, References, and Index updated.
  04/01/2008 A NOTE was added after the Reconstructive definition to clarify that not all benefit contracts include a reconstructive services benefit. Coding updated.
Revised 11/29/2007 MPTAC review. Clarification of Position Statements. Revision of Position Statement for reconstructive rhinoplasty for nasal fractures. Not medically necessary statement added for cranial nerve procedures to align with existing coding.  Background, Coding and References updated. The phrase "cosmetic/not medically necessary" was clarified to read "cosmetic and not medically necessary."
Reviewed 12/07/2006 MPTAC review. References updated.
  01/01/2007 Updated Coding section with 01/01/2007 CPT/HCPCS changes.
Revised 12/01/2005 MPTAC review. Provided clarification of Position Statement for when otoplasty is considered reconstructive.
  11/21/2005 Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Reviewed 09/22/2005 MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organizations Last Review Date Document Number Title

Anthem, Inc.

 

04/28/2005 ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
WellPoint Health Networks, Inc. 04/28/2005 3.03.04 Otoplasty
  04/28/2005 Clinical Document Reconstruction of the External Ear
  04/28/2005 Clinical Document Rhinoplasty