Medical Policy



Subject: Cosmetic and Reconstructive Services of the Trunk and Groin
Document #: ANC.00009 Current Effective Date:    03/29/2017
Status: Reviewed Last Review Date:    02/02/2017

Description/Scope

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:

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.

Position Statement

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 by measuring the transverse diameter of the thorax 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 by measuring the transverse diameter of the thorax 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 Genitalia:

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

  1. Labia minora reduction
  2. Labia major reshaping
  3. Clitoral reduction
  4. Hymenoplasty
  5. Pubic liposuction or lift
  6. Phalloplasty

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

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

Rationale

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.

Congenital abnormalities of the trunk and groin
Correction of a congenital abnormality may be considered when there is evidence that the abnormality results in a significant physical functional impairment and the procedure can be reasonably expected to improve the physical functional impairment. There is no evidence to support surgical correction or repair of conditions such as congenital chordee, hypospadias, penile torsion or, congenital buried or concealed penis in the absence of significant physical functional impairment.

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 1 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 (for example, 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. Lawson and colleagues (2011) reported on the association of severity of PE and the impact on pulmonary function. The authors concluded that individuals with PE demonstrated an:

Increased depth of chest depression is related to an increased likelihood of below-normal pulmonary function, primarily with a restrictive pattern. Future studies should examine other measures in combination with depth of depression to increase our understanding of the mechanisms and impact of this deformity in cardiopulmonary function in both the resting and exercising states.

The Haller index is the most commonly used scale for the measurement of chest deformity in individuals with pectus excavatum. 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 (Croitoru, 2012; Lawson, 2011; Nuss, 1998; Nuss, 2002).

As with pectus excavatum, the measurement of pectus carinatum, also called pigeon chest 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).

Background/Overview

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, also known as funnel chest, is the most common chest wall deformity; this abnormality is 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 1 to 2 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 2 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) or magnetic resonance imaging (MRI). 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 is the second most common congenital chest wall deformity, 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 vaginal anatomy. 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, in the absence of a functional impairment. Enlargement may be desired in cases of abnormally small penis size.

Definitions

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.

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.  Brachioplasty
When services may be Medically Necessary when criteria are met:

CPT  
15836 Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm
   
ICD-10 Procedure  
0JDD0ZZ-0JDF0ZZ Extraction of subcutaneous tissue and fascia, upper arm, open approach [right or left; includes codes 0JDD0ZZ, 0JDF0ZZ]
0J0D0ZZ-0J0F0ZZ Alteration of subcutaneous tissue and fascia [arm, by approach; includes codes 0J0D0ZZ, 0J0F0ZZ]
   
ICD-10 Diagnosis  
  All diagnoses

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: 

CPT  
15832 Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
15833 Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg
15834 Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip
15835 Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock
   
ICD-10 Procedure  
0JD90ZZ Extraction of buttock subcutaneous tissue and fascia, open approach
0JDC0ZZ Extraction of pelvic region subcutaneous tissue and fascia, open approach
0JDL0ZZ-0JDM0ZZ Extraction of upper leg subcutaneous tissue and fascia, open approach [right or left; includes codes 0JDL0ZZ, 0JDM0ZZ]
0J090ZZ Alteration of buttock subcutaneous tissue and fascia, open approach
0J0L0ZZ-0J0M0ZZ Alteration of subcutaneous tissue and fascia, upper leg, open approach [right or left; includes codes 0J0L0ZZ, 0J0M0ZZ]
   
ICD-10 Diagnosis  
  All diagnoses

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:

ICD-10 Procedure  
0Y0007Z-0Y0147Z Alteration of buttock with autologous tissue substitute [right or left, by approach; includes codes 0Y0007Z, 0Y0037Z, 0Y0047Z, 0Y0107Z, 0Y0137Z, 0Y0147Z]
0Y000JZ-0Y014JZ Alteration of buttock with synthetic substitute [right or left, by approach; includes codes 0Y000JZ, 0Y003JZ, 0Y004JZ, 0Y010JZ, 0Y013JZ, 0Y014JZ]
0Y000KZ-0Y014KZ Alteration of buttock with nonautologous tissue substitute [right or left, by approach; includes codes 0Y000KZ, 0Y003KZ, 0Y004KZ, 0Y010KZ, 0Y013KZ, 0Y014KZ]
0Y000ZZ-0Y014ZZ Alteration of buttock [right or left, by approach; includes codes 0Y000ZZ, 0Y003ZZ, 0Y004ZZ, 0Y010ZZ, 0Y013ZZ, 0Y014ZZ]
   
ICD-10 Diagnosis  
  All diagnoses

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

CPT  
15877 Suction assisted lipectomy; trunk
   
ICD-10 Procedure  
0J060ZZ-0J063ZZ Alteration of chest subcutaneous tissue and fascia [by approach, includes codes 0J060ZZ, 0J063ZZ]
0JD60ZZ-0JD63ZZ Extraction of chest subcutaneous tissue and fascia [by approach; includes codes 0JD60ZZ, 0JD63ZZ]
   
ICD-10 Diagnosis  
N65.0-N65.1 Deformity and disproportion of reconstructed breast
Z42.1 Encounter for breast reconstruction following mastectomy
Z85.3 Personal history of malignant neoplasm of breast
Z90.10-Z90.13 Acquired absence of breast and nipple

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:

CPT  
15837 Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand
15839 Excision, excessive skin and subcutaneous tissue (includes lipectomy), other area
15878 Suction assisted lipectomy; upper extremity
15879 Suction assisted lipectomy; lower extremity
   
ICD-10 Procedure  
0J070ZZ-0J073ZZ Alteration of back subcutaneous tissue and fascia [by approach, includes codes 0J070ZZ, 0J073ZZ]
0J093ZZ Alteration of buttock subcutaneous tissue and fascia, percutaneous approach
0J0D3ZZ-0J0F3ZZ Alteration of upper arm subcutaneous tissue and fascia, percutaneous approach [right or left; includes codes 0J0D3ZZ, 0J0F3ZZ]
0J0G0ZZ-0J0H3ZZ Alteration of lower arm subcutaneous tissue and fascia [right or left by approach; includes codes 0J0G0ZZ, 0J0G3ZZ, 0J0H0ZZ, 0J0H3ZZ]
0J0L3ZZ-0J0M3ZZ Alteration of upper leg subcutaneous tissue and fascia [right or left, percutaneous approach; includes codes  0J0L3ZZ, 0J0M3ZZ]
0J0N0ZZ-0J0P3ZZ Alteration of lower leg subcutaneous tissue and fascia [right or left by approach; includes codes 0J0N0ZZ, 0J0N3ZZ, 0J0P0ZZ, 0J0P3ZZ]
0JD70ZZ-0JD73ZZ Extraction of back subcutaneous tissue and fascia [by approach; includes codes 0JD70ZZ, 0JD73ZZ]
0JD93ZZ Extraction of buttock subcutaneous tissue and fascia, percutaneous approach
0JDB0ZZ-0JDB3ZZ Extraction of perineum subcutaneous tissue and fascia [by approach; includes codes 0JDB0ZZ-0JDB3ZZ]
0JDC3ZZ Extraction of pelvic region subcutaneous tissue and fascia, percutaneous approach
0JDD3ZZ- 0JDF3ZZ Extraction of subcutaneous tissue and fascia, upper arm, percutaneous approach [right or left; includes codes 0JDD3ZZ, 0JDF3ZZ]
0JDG0ZZ-0JDK3ZZ Extraction of lower arm and hand subcutaneous tissue and fascia [right or left, by approach; includes codes 0JDG0ZZ, 0JDG3ZZ, 0JDH0ZZ, 0JDH3ZZ, 0JDJ0ZZ, 0JDJ3ZZ, 0JDK0ZZ, 0JDK3ZZ]
0JDL3ZZ-0JDM3ZZ Extraction of upper leg subcutaneous tissue and fascia, percutaneous approach [right or left; includes codes 0JDL3ZZ, 0JDM3ZZ]
0JDN0ZZ-0JDR3ZZ Extraction of lower leg or foot subcutaneous tissue and fascia [right or left, by approach; includes codes, 0JDN0ZZ, 0JDN3ZZ, 0JDP0ZZ, 0JDP3ZZ, 0JDQ0ZZ, 0JDQ3ZZ, 0JDR0ZZ, 0JDR3ZZ]
   
ICD-10 Diagnosis  
  All diagnoses

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

CPT  
21740 Reconstructive repair of pectus excavatum or carinatum; open
21742 Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy
21743 Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy
   
ICD-10 Procedure  
0PS000Z-0PS040Z Reposition sternum with rigid plate internal fixation device [by approach; includes codes 0PS000Z, 0PS030Z, 0PS040Z]
0PS004Z-0PS044Z Reposition sternum with internal fixation device [by approach, includes codes 0PS004Z, 0PS034Z, 0PS044Z]
0WU80JZ Supplement chest wall with synthetic substitute, open approach
0WU84JZ Supplement chest wall with synthetic substitute, percutaneous endoscopic approach
   
ICD-10 Diagnosis  
E64.3 Sequelae of rickets
M95.4 Acquired deformity of chest and rib
Q67.6 Pectus excavatum
Q67.7 Pectus carinatum

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

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

CPT  
54360 Plastic operation on penis to correct angulation
54440 Plastic operation on penis for injury
56800 Plastic repair of introitus
56805 Clitoroplasty for intersex state
56810 Perineoplasty, repair of perineum, nonobstetrical (separate procedure)
57291 Construction of artificial vagina, without graft
57292 Construction of artificial vagina, with graft
57335 Vaginoplasty for intersex state
   
ICD-10 Procedure  
0UBJXZZ Excision of clitoris, external approach
0UMK0ZZ-0UMK4ZZ Reattachment of hymen [by approach; includes codes 0UMK0ZZ, 0UMK4ZZ]
0UQG0ZZ-0UQGXZZ Repair vagina [by approach; includes codes 0UQG0ZZ, 0UQG3ZZ, 0UQG4ZZ, 0UQG7ZZ, 0UQG8ZZ, 0UQGXZZ]
0UQJ0ZZ-0UQJXZZ Repair clitoris [by approach; includes codes 0UQJ0ZZ, 0UQJXZZ]
0UQK0ZZ-0UQKXZZ Repair hymen [by approach; includes codes 0UQK0ZZ, 0UQK3ZZ, 0UQK4ZZ, 0UQK7ZZ, 0UQK8ZZ, 0UQKXZZ]
0UQM0ZZ-0UQMXZZ Repair vulva [by approach; includes codes 0UQM0ZZ, 0UQMXZZ]
0UTJXZZ Resection of clitoris, external approach
0UTMXZZ Resection of vulva, external approach
0VUS07Z-0VUSX7Z Supplement penis with autologous tissue substitute [by approach; includes codes 0VUS07Z, 0VUS47Z, 0VUSX7Z]
0VUS0KZ-0VUSXKZ Supplement penis with nonautologous tissue substitute [by approach; includes codes 0VUS0KZ, 0VUS4KZ, 0VUSXKZ]
0W0M07Z-0W0M47Z Alteration of male perineum with autologous tissue substitute [by approach; includes codes 0W0M07Z, 0W0M37Z, 0W0M47Z]
0W0M0JZ-0W0M4JZ Alteration of male perineum with synthetic substitute [by approach; includes codes 0W0M0JZ, 0W0M3JZ, 0W0M4JZ]
0W0M0KZ-0W0M4KZ Alteration of male perineum with nonautologous tissue substitute [by approach; includes codes 0W0M0KZ, 0W0M3KZ, 0W0M4KZ]
0W0M0ZZ-0W0M4ZZ Alteration of male perineum [by approach; includes codes 0W0M0ZZ, 0W0M3ZZ, 0W0M4ZZ]
0W0N07Z-0W0N47Z Alteration of female perineum with autologous tissue substitute [by approach; includes codes 0W0N07Z, 0W0N37Z, 0W0N47Z]
0W0N0JZ-0W0N4JZ Alteration of female perineum with synthetic substitute [by approach; includes codes 0W0N0JZ, 0W0N3JZ, 0W0N4JZ]
0W0N0KZ-0W0N4KZ Alteration of female perineum with nonautologous tissue substitute [by approach; includes codes 0W0N0KZ, 0W0N3KZ, 0W0N4KZ]
0W0N0ZZ-0W0N4ZZ Alteration of female perineum [by approach; includes codes 0W0N0ZZ, 0W0N3ZZ, 0W0N4ZZ]
   
ICD-10 Diagnosis  
  All diagnoses
   
References

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. De Oliveira Carvaldo PE, de Silva MVM, Rodrigues OR, Cataneo AJM. Surgical interventions for treatment pectus excavatum. Cochrane Database of Sys Rev. 2014;(10):CD008889.
  6. Eroglu E, Gundogdu G. Isolated penile torsion in newborns. Can Urol Assoc J. 2015; 9(11-12):E805-E807.
  7. 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.
  8. 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.
  9. Fonkalsrud EW, Mendoza J. Open repair of pectus excavatum and carinatum deformities with minimal cartilage resection. Am J Surg. 2006; 191(6):779-784.
  10. Forner-Cordero, I., et al. Lipedema: An overview of its clinical manifestations, diagnosis and treatment of the disproportional fatty deposition syndrome – systematic review. Clin Obes. 2012; 2(3-4):86-95.
  11. Frantz FW. Indications and guidelines for pectus excavatum repair. Curr Opin Pediatr. 2011; 23:486-491.
  12. 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.
  13. 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.
  14. Huddleston CB. Pectus excavatum. Semin Thorac Cardiovasc Surg. 2004; 16(3):225-232.
  15. 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.
  16. 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.
  17. 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.
  18. Lawson ML, Mellins RB, Paulson JF, et al. Increasing severity of pectus excavatum is associated with reduced pulmonary function. J Pediatr. 2011; 159:256-261.
  19. 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.
  20. 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.
  21. 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.
  22. 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.
  23. 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.
  24. 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.
  25. Obermeyer RJ, Goretsky MJ. Chest wall deformities in pediatric surgery. Surg Clin N Am. 2012; 92:669-684.
  26. 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.
  27. 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.
  28. Shamberger RC. Cardiopulmonary effects of anterior chest wall deformities. Chest Surg Clin N Am. 2000; 10(2):245-252.
  29. Sigalet DL, Montgomery M, Harder J. Cardiopulmonary effects of closed repair of pectus excavatum. J Pediatr Surg. 2003; 38(3):380-385.
  30. 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.
  31. Tanner H, Bischof D, Roten L, et al. Electrocardiographic characteristics of patients with funnel chest before and after surgical correction using pectus bar: A new association with precordial J wave pattern. J Electrocardiol. 2016; 49(2):174-181.
  32. 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.
Websites for Additional Information
  1. American Society for Aesthetic Plastic Surgery. Available at: http://www.surgery.org/. Accessed December 14, 2016.
  2. American Academy of Facial Plastic and Reconstructive Surgery. Available at: http://www.aafprs.org/. Accessed December 14, 2016.
  3. American Society of Plastic Surgeons. Available at: http://www.plasticsurgery.org . Accessed December 14, 2016.
Index

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

Document History
Status Date Action
Reviewed 02/02/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section.
Revised 02/04/2016 MPTAC review. Revised cosmetic and not medically necessary statement to address procedures on external genitalia. Revised reconstructive statement to addressing genitalia.  Removed ICD-9 codes from Coding section.
Reviewed 08/06/2015 MPTAC review. Updated References.
Reviewed 08/14/2014 MPTAC review. References and Websites Updated.
Revised 08/08/2013 MPTAC review. Clarified note that defines how Haller index is measured for pectus excavatum and pectus carinatum. Updated Background and Websites.
Revised 08/09/2012 MPTAC review. Clarified medically necessary statement for brachioplasty. Added medically necessary statement for buttock & thigh lift. Added reconstructive statement for lipectomy/liposuction when done to address significant variant from normal directly related to surgical mastectomy. Clarified cosmetic and not medically necessary statements for buttock & thigh lift and lipectomy/liposuction. Rationale, Background, Coding, Websites and References sections updated.
Reviewed 05/10/2012 MPTAC review. Websites and References sections updated.
Reviewed 05/19/2011 MPTAC review. References and websites updated.
Reviewed 05/13/2010 MPTAC review. References and websites updated.
Reviewed 05/21/2009 MPTAC review. References updated.
Revised 05/15/2008 MPTAC review. Added reconstructive criteria for pectus excavatum and for pectus carinatum. Added cosmetic and not medically necessary statement for pectus excavatum and for pectus carinatum. Updated Reference section.
Revised 11/29/2007 MPTAC review. Added medically necessary statement to Brachioplasty section when significant physical functional impairment is present. Added reconstructive statement for congenital abnormalities. Changed not medically necessary statement for congenital abnormalities to be cosmetic/not medically necessary. Revised wording in Lipectomy/liposuction section to add "for all indications, including but not limited to the removal of excess fat from the thighs, buttocks, chest or abdomen." The phrase "cosmetic/not medically necessary" was clarified to read "cosmetic and not medically necessary."   Updated coding and reference section.
Reviewed 03/08/2007 MPTAC review. No change to position statement. Updated reference section.
Revised 03/23/2006 MPTAC review. Added clarification and references regarding physiological impairment associated with pectus excavatum.
Revised 12/01/2005 MPTAC review. Added procedures of male and female genitalia. 
  11/22/2005 Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Revised 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.

06/16/2003

ANC.00009 Cosmetic and Reconstructive Services of the Trunk and Groin
WellPoint Health Networks, Inc.

04/28/2005

3.01.25

Surgical Treatment of Pectus Excavatum
 

09/23/2004

 

Clinical Guideline: Liposuction