Medical Policy |
Subject: Cosmetic and Reconstructive Services of the Head and Neck | |
Document #: ANC.00008 | Publish Date: 04/10/2024 |
Status: Reviewed | Last Review Date: 02/15/2024 |
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: This document does not address gender affirming surgery or procedures. Criteria for gender affirming surgery or procedures are found in applicable guidelines used by the plan.
Note:
Note: The use of botulinum toxin is not addressed in this document.
Medically Necessary: In this document, procedures are considered medically necessary if there is a significant functional impairment AND the procedure can be reasonably expected to improve the 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 functional impairment and the procedure can be reasonably expected to improve the 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:
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.
Otoplasty using a custom-fabricated device, including but not limited to a custom fabricated alloplastic implant, is considered cosmetic and not medically necessary.
C. Rhinophyma
Excision or shaving of the rhinophyma is considered medically necessary when both of the following criteria are met:
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:
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 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 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 functional impairment and the procedure can be reasonably expected to improve the functional impairment. Examples of cranial nerve procedures to correct a 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 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 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 (anotia) at birth, or has been deformed as a result of trauma. Atresia refers to a more severe condition in which the individual lacks an external auditory canal. Microtia and anotia may be found in congenital conditions affecting development of the first and second branchial arches, such as Goldenhar syndrome, hemifacial microsomia, and Treacher-Collins syndrome. They can also be associated with congenital malformations of the face, limbs, heart, or kidneys, or with maternal exposure to teratogens.
Otoplasty is considered reconstructive when it is intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect. When no reconstructive indication is present, otoplasty is considered cosmetic if there is no functional impairment.
The structural framework used to develop the reconstructed ear is made using costal cartilage or an alternative device, commonly a biocompatible porous polyethylene implant. Costal reconstruction is a four-stage procedure using a second surgical site, typically a rib, to harvest autologous material. While costal reconstruction is more complex and invasive, it is considered more durable, with a lower infection rate and a good cosmetic result. Alloplastic devices are less invasive and can be used in situations where costal harvesting cannot be performed, but they are associated with a higher rate of extrusion and infection (Siegert, 2019). For both techniques, a template is created based on radiographs of the normal ear, or of a family member’s ear in the case of bilateral microtia. A prefabricated device is typically comprised of 2 pieces, which are then trimmed and custom fitted to size using the template and assembled using sutures or welds (Constantine, 2014). Alternatively, custom fabricated implants are typically a 1-piece implant created using 3D imaging.
Rhinophyma is a condition where the nose becomes enlarged, red in color, and bulbous. The cause of rhinophyma is unknown but has been associated with rosacea, a chronic skin rash that is characterized by reddening of the skin on the face. 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 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 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 functional impairment, disease, or injury-related facial changes.
Nerve anastomosis or grafting, decompression, and peripheral neuroplasty are examples of surgical procedures performed to correct functional impairment that may result from cranial and facial nerve pathology, injury or dysfunction. These procedures are expected to improve the individual’s 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 (eg, 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 (eg, 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 |
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ICD-10 Procedure | |
0NU107Z-0NU10KZ | Supplement frontal bone, open approach; [with autologous tissue, synthetic or nonautologous tissue substitute; includes codes 0NU107Z, 0NU10JZ, 0NU10KZ] |
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] |
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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 |
|
21086 | Impression and custom preparation; auricular prosthesis |
69300 | Otoplasty, protruding ear, with or without size reduction |
69399 | Unlisted procedure, external ear [when specified as other otoplasty] |
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|
HCPCS |
|
L8045 | Auricular prosthesis, provided by a nonphysician |
L8699 | Prosthetic implant, not otherwise specified [when describing a prefabricated, custom-fitted auricular implant] |
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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] |
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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, including the following
HCPCS |
|
L8699 | Prosthetic implant, not otherwise specified [when describing a custom-fabricated auricular implant] |
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ICD-10 Diagnosis |
|
| All diagnoses |
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 |
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ICD-10 Procedure | |
0HB1XZZ | Excision of face skin, external approach |
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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] |
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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] |
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|
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 |
15829 | Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap |
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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 |
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|
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] |
64866-64868 | Anastomosis (facial nerves) [includes codes 64866, 64868] |
69955 | Total facial nerve decompression and/or repair (may include graft) |
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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 |
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:
Government Agency, Medical Society, and Other Authoritative Publications:
Websites for Additional Information |
Index |
Crouzon Syndrome
Goldenhar Syndrome
Lower Rhytidectomy
Neck Lift
Parry-Romberg Syndrome
Platysmaplasty
Rhytidectomy
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 | 02/15/2024 | Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section. Updated Coding section to add CPT code 21086 and HCPCS code L8045. |
| 09/27/2023 | Updated Coding section regarding SMAS flap rhytidectomy, may be considered reconstructive when criteria are met. |
Reviewed | 02/16/2023 | MPTAC review. Updated Description, Background and References sections. |
Reviewed | 02/17/2022 | MPTAC review. Updated References section. |
Revised | 02/11/2021 | MPTAC review. Added cosmetic and not medically necessary statement regarding custom fabricated implants used in otoplasty. Removed term “physical” from the term “physical functional impairment” in the Facial Plastic Surgery, Otoplasty, Rhinophyma, Rhinoplasty or Rhinoseptoplasty and Cranial Nerve Procedures position statements. Updated Rationale, Background and References sections. Updated Coding section; added L8699, removed deleted ICD-10-PCS codes. |
Reviewed | 02/20/2020 | MPTAC review. Updated References section. |
Reviewed | 03/21/2019 | MPTAC review. Updated References. |
Reviewed | 03/22/2018 | MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated References and Websites sections. |
Reviewed | 05/04/2017 | 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 |
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.
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