Current CPT codes do not allow distinction of cosmetic or reconstructive procedures by specific codes; therefore, categorization of each procedure is to be distinguished by the presence or absence of specific signs and/or symptoms.When nasal surgery is performed solely to improve the patient’s appearance in the absence of any signs and/or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and noncovered under the Medicare program.Benefits are provided for complications arising from cosmetic surgery as long as infection, hemorrhage or other serious documented medical complication occurs and the beneficiary has been officially discharged from the facility.Abdominal lipectomy/panniculectomy is surgical removal of excessive fat and skin from the abdomen.For Medicare purposes, a reasonable and necessary reduction mammoplasty could be indicated in the presence of significantly enlarged breasts and the presence of at least one of the following signs and/or symptoms: Considerable attention has been given to the amount of breast tissue removed in differentiating between cosmetic and medically necessary reduction mammoplasty.Arbitrary minimum weight breast tissue removed criteria do not consistently reflect the consequences of mammary hypertrophy in individuals with a unique body habitus.The patient’s physical appearance may contribute to psychological conditions (e.g., depression) or adversely impact a patient’s adherence to antiretroviral regimens (therefore jeopardizing their health) and both of these are important health-related outcomes of interest in this population.
This surgery may be performed to improve abnormal function, reconstruct congenital or acquired deformities, or to enhance appearance.
Corrective facial surgery will be considered cosmetic rather than reconstructive when there is no functional impairment present.
However, some congenital, acquired, traumatic or developmental anomalies may not result in functional impairment, but are so severely disfiguring as to merit consideration for corrective surgery.
Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.
Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.