Cosmetic vs Reconstructive Surgery - JF Part A

Section 1862(a)(1)(A) of Title XVIII of the Social Security Act provides in part that "…no payment may be made under Part A or B (of Medicare) for any expenses incurred for items or services which… are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member."

Cosmetic Surgery

Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem. Surgery performed to improve on "natural" appearance or performed purely for the purpose of enhancing one's normal appearance is not considered reasonable and necessary.

Cosmetic Clinical Indications

• Corrective facial surgery is usually not covered when there is no functional impairment being addressed;
• A mastopexy performed primarily to lift or reshape the breast and unrelated to breast reconstruction following surgery for breast cancer is not covered;
• A reduction mammoplasty to improve the appearance of the breast is not covered; however this may be an approved surgery for sagging breast, if patient has appropriate symptoms and size;
• Suction assisted lipectomy to remove localized collections of unwanted fat in order to improve appearance is not covered
• Nasal surgery to improve appearance is not covered in the absence of signs and symptoms of functional abnormalities
• Eye surgery that does not correct a functional impairment is not covered; and
• Reimbursement for a non-covered procedure performed at the same operative session as a covered surgical procedure will not be allowed.

Reconstructive Surgery

Reconstructive surgery is performed to restore bodily function or to correct a deformity resulting from disease, injury, trauma, birth defects, congenital anomalies, infections, burns or previous medical treatment, such as surgery or radiation therapy. Reconstructive surgery is reasonable and necessary when the purpose is to improve necessary functioning of a malformed body part whereas surgery addressing appearance alone is considered cosmetic and not covered.

Reconstructive Clinical Indications

• Surgical procedures to replace significant absent breast tissue secondary to prior tumor removal, trauma, infection or to correct a gross variation in breast size, that is developmental or post-mastectomy;
• Breast augmentation or reduction mammoplasty is covered in the presence of a significant acquired deformity of the breast and breast carcinoma;
• Removal of breast implants for any of the following conditions may be medically necessary:
  • Broken or failed implant;
  • Infection;
  • Implant extrusion;
  • Siliconoma or granuloma;
  • Interference with diagnosis of breast cancer;
  • Breast pain; and
  • Painful capsular contraction.
• The surgical removal of excessive fat and skin from the abdomen when the surgery is to alleviate complicating factors such as:
  • Inability to walk normally;
  • Chronic pain; and
  • Ulceration or infection created by the abdominal skin fold or severe and recurrent dermatitis.
• Suction assisted lipectomy to remove a lipoma, unless the lipoma is the etiology of critical symptoms or other disease such as erosion or obstruction of a contiguous structure;
• Repair of the upper eyelid when skin is sufficiently low to produce dysfunction of significant visual field impairment; and
• Nasal surgery generally performed to improve the following:
  • Respiratory function;
  • Repair defects caused by trauma;
  • Treat congenital anatomic anomalies; such as cleft lip nasal deformities, choanal atreia, and oronasal or oromaxillary fistula; and
  • Replace nasal tissue lost after tumor ablation

Clinical documentation, indicating the significant clinical signs and symptoms and pre-operative photographs, visual fields or pathology reports must be available and submitted if requested to support medical necessity of the reconstructive procedures.

Resource

• CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 120