CPT/HCPCS Codes and Description
Group 1
15780© Abrasion treatment of skin
15781© Abrasion treatment of skin
15782© Abrasion treatment of skin
15783© Abrasion treatment of skin
Group 2
15830 Exc skin abd
15847 Exc skin abd add-on
Group 3
19316© Suspension of breast
19324© Enlarge breast
19325© Enlarge breast with implant
19328© Removal of breast implant
19330© Removal of implant material
19340© Immediate breast prosthesis
19342© Delayed breast prosthesis
19350© Breast reconstruction
19355© Correct inverted nipple(s)
19357© Breast reconstruction
19361© Breast reconstr w/lat flap
19364© Breast reconstruction
19366© Breast reconstruction
19367© Breast reconstruction
19368© Breast reconstruction
19369© Breast reconstruction
19370© Surgery of breast capsule
19371© Removal of breast capsule
19380© Revise breast reconstruction
19396© Design custom breast implant
Group 4
19318© Reduction of large breast
Group 5
30400© Reconstruction of nose
30410© Reconstruction of nose
30420© Reconstruction of nose
30430© Revision of nose
30435© Revision of nose
30450© Revision of nose
30460© Revision of nose
30462© Nose for cleft palate pat
Group 6
C9800 Dermal injection of fillers (Sculptra®/Radiesse®)
Note: C9800 for ASC and OPPS only
G0429 Dermal injection of fillers (Sculptra®/Radiesse®)
Q2026 Dermal filler Sculptra®
Q2027 Dermal filler Radiesse®
Reconstructive Surgery
Reconstructive surgery is performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function but may also be done to approximate a normal appearance.
Cosmetic Surgery
Cosmetic surgery is performed to reshape normal structures of the body to improve the patient’s appearance and self-esteem.
Cosmetic surgery performed purely for the purpose of enhancing one’s appearance is not eligible for coverage.
However, surgery to correct congenital defects, developmental abnormalities, trauma, infections, tumors, or disease may be covered because the surgery is considered reconstructive in nature.
Cosmetic surgery performed to treat psychiatric or emotional problems is generally not covered.
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.
If a non-covered cosmetic surgery is performed in the same operative period as a covered surgical procedure, benefits will be provided for the covered surgical procedure only.
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.
Payment will be made for the following procedures when performed for the reasons indicated:
Group 1: Dermabrasion
Coverage will be provided when correcting defects resulting from traumatic injury, surgery or disease.
Dermabrasion performed for post-acne scarring is classified as cosmetic and is not covered for payment.
Group 2: Abdominal Lipectomy/Panniculectomy
Abdominal lipectomy/panniculectomy is surgical removal of excessive fat and skin from the abdomen. When surgery is performed to alleviate such complicating factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigal dermatitis, such surgery is considered reconstructive. Preoperative photographs may be required to support justification and should be supplied upon request.
TrailBlazer considers panniculectomy medically necessary when the panniculus hangs below the level of the pubis, andthe medical records document that the panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs over three months while receiving appropriate medical therapy, or remains refractory to appropriate medical therapy over a period of three months.
TrailBlazer considers panniculectomy experimental and investigational for minimizing the risk of hernia formation or recurrence. There is no adequate evidence that pannus contributes to hernia formation. The primary cause of hernia formation is an abdominal wall defect or weakness, not a pulling effect from a large or redundant pannus.
Note: If the procedure is being performed following significant weight loss, in addition to meeting the criteria noted above, there should be evidence that the individual has maintained a stable weight for at least three to six months. If the weight loss is the result of bariatric surgery, abdominoplasty/panniculectomy should generally not be performed until at least 18 months after bariatric surgery and only when weight has been stable for at least the most recent three to six months.
TrailBlazer does not cover abdominoplasty or panniculectomy when performed primarily for any of the following indications because it is considered not medically necessary (this list may not be all inclusive):
Treatment of neck or back pain.
Improving appearance (i.e., cosmesis).
Repairing abdominal wall laxity or diastasis recti.
Treating psychological symptomatology or psychosocial complaints.
When performed in conjunction with abdominal or gynecological procedures (e.g., abdominal hernia repair, hysterectomy, obesity surgery) unless criteria for panniculectomy and abdominoplasty are met separately.
Group 3: Reconstructive Breast Surgery: Removal of Breast Implants
For a patient who has had an implant(s) placed for reconstructive or cosmetic purposes, Medicare considers treatment of any one or more of the following conditions to be medically necessary:
Broken or failed implant.
Infection.
Implant extrusion.
Siliconoma or granuloma.
Interference with diagnosis of breast cancer.
Painful capsular contracture with disfigurement.
Group 4: Reduction Mammoplasty
Macromastia (breast hypertrophy) is disproportionate volume and weight of breast tissue relative to the general body habitus. Breast hypertrophy may adversely affect other body systems (e.g., musculoskeletal, respiratory, integumentary). Unilateral hypertrophy may result in symptoms following contralateral mastectomy.
Reduction mammoplasty is performed:
To reduce the size of the breasts and help ameliorate symptoms caused by hypertrophy.
To reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery.
Medicare medical necessity for reduction mammoplasty is limited to circumstances in which:
There are signs and/or symptoms resulting from the enlarged breasts (macromastia) that have not responded adequately to non-surgical interventions.
To improve symmetry following cancer surgery on one breast.
Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit. Cosmetic signs and/or symptoms would include ptosis, poorly fitting clothing and beneficiary perception of unacceptable appearance.
Non-surgical interventions preceding reduction mammoplasty should include as appropriate, but are not limited to, the following:
Determining the macromastia is not due to an active endocrine or metabolic process.
Determining the symptoms are refractory to appropriately fitted supporting garments, or following unilateral mastectomy, persistent with an appropriately fitted prosthesis or reconstruction therapy at the site of the absent breast.
Determining that dermatologic signs and/or symptoms are refractory to, or recurrent following a completed course of medical management.
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:
Back pain from macromastia, unrelieved by:
Conservative analgesia.
Supportive measures (garment, etc.).
Physical therapy.
Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity.
Intertriginous maceration or infection of the inframammary skin refractory to dermatologic measures.
Shoulder grooving with skin irritation by supporting garment (bra strap).
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. There are wide variations in the range of height, weight and associated breast size that cause symptoms. The amount of tissue that must be removed to relieve symptoms will vary and depend upon these variations. The following are guidelines (not rules) that address the patient’s weight and the amount of breast tissue removed:
Table I
95–119 lbs. 300 grams excised per breast.
110–130 lbs. 400 grams excised per breast.
130+ lbs. 500 grams excised per breast.
Medicare coverage of reduction mammoplasty is limited to those circumstances where the medical record supports the following:
The signs and/or symptoms have been present for at least six months.
Medical treatment and/or physical interventions have not adequately alleviated symptoms.
Group 5: Rhinoplasty
Nasal surgery is defined as any procedure performed on the external or internal structures of the nose, septum or turbinate. This surgery may be performed to improve abnormal function, reconstruct congenital or acquired deformities, or to enhance appearance. It generally involves rearrangement or excision of the supporting bony and cartilaginous structures and incision or excision of the overlying skin of the nose.
Nasal surgery, including rhinoplasty, may be reconstructive or cosmetic in nature. 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.
Cosmetic Nasal Surgery
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.
Reconstructive Nasal Surgery
When nasal surgery, including rhinoplasty, is performed to improve nasal respiratory function, correct anatomic abnormalities caused by birth defects or disease, or revise structural deformities produced by trauma, the procedure should be considered reconstructive.
TrailBlazer covers rhinoplasty as medically necessary when there is photographic documentation (all of the following: frontal, lateral and worm’s eye view) of the individual’s condition, and the procedure is performed for correction or repair of any of the following:
Nasal deformity secondary to a cleft lip/palate or other congenital craniofacial deformity causing a functional impairment.
Chronic, non-septal, nasal obstruction due to vestibular stenosis (i.e., collapsed internal valves).
Secondary to trauma, disease, congenital defect with nasal airway obstruction unresponsive to a recent trial of conservative medical management lasting at least six weeks that has either not resolved after previous septoplasty/turbinectomy or would not be expected to resolve with septoplasty/turbinectomy alone.
TrailBlazer does not cover rhinoplasty when performed for either of the following indications because it is considered cosmetic in nature or not medically necessary:
Solely for the purpose of changing appearance.
As a primary treatment for an obstructive sleep disorder when the above criteria for approval have not been met.
TrailBlazer covers septoplasty as medically necessary when performed for any of the following indications:
Septal deviation causing nasal airway obstruction that has proved unresponsive to a recent trial of conservative medical management lasting at least six weeks.
Recurrent sinusitis secondary to a deviated septum that does not resolve after appropriate medical and antibiotic therapy.
Recurrent epistaxis related to a septal deformity.
Asymptomatic septal deformity that prevents access to other transnasal areas when such access is required to perform medically necessary procedures (e.g., ethmoidectomy).
Performed in association with cleft lip or cleft palate repair.
Obstructed nasal breathing due to septal deformity or deviation that has proved unresponsive to medical management and is interfering with the effective use of medically necessary Continuous Positive Airway Pressure (CPAP) for the treatment of an obstructive sleep disorder.
Reconstructive nasal surgery is generally directed to improve nasal respiratory function (e.g., airway obstruction or stricture, synechia formation); repair defects caused by trauma (e.g., nasoseptal deviation, intranasal cicatrix, dislocated nasal bone fractures, turbinate hypertrophy); treat congenital anatomic abnormalities (e.g., cleft lip nasal deformities, choanal atresia, oronasal or oromaxillary fistula); treat nasal cutaneous disease (e.g., rhinophyma, dermoid cyst); or to replace nasal tissue lost after tumor ablative surgery.
Services billed with a diagnosis code that is not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this policy will be denied as not covered. Exceptions will be considered on a case-by-case basis.
Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.
Group 6: Dermal Injections
Facial Lipodystrophy Syndrome (FLS) is often characterized by a loss of fat that results in a facial abnormality such as severely sunken cheeks. 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. Therefore, improving a patient’s physical appearance through the use of dermal injections could improve these health-related outcomes.
Dermal injections for FLS are only reasonable and necessary using dermal fillers approved by the Food and Drug Administration (FDA) for this purpose, and then only in HIV-infected beneficiaries when FLS caused by antiretroviral HIV treatment is a significant contributor to their depression.
LCD Individual Consideration
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.
For example, the craniofacial anomalies associated with Treacher Collins’ syndrome should be reviewed on an individual consideration basis.
Safe and effective.
Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
Furnished in a setting appropriate to the patient’s medical needs and condition.
Ordered and furnished by qualified personnel.
One that meets, but does not exceed, the patient’s medical need.
At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
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. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
11X, 13X, 71X, 73X, 77X, 83X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X is effective for dates of service on or after April 1, 2010.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual, Pub. 100-04, Claims Processing Manual, for further guidance.
036X, 045X, 049X, 051X, 052X, 076X
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Group 1
Medicare is establishing the following limited coverage for dermabrasion (CPT/HCPCS codes 15780, 15781, 15782 and 15783):
Covered for:
695.3
Rosacea
Group 2
Medicare is establishing the following limited coverage for abdominal lipectomy/panniculectomy
(CPT/HCPCS codes 15830 and 15847):
Covered for:
551.20–551.21
Ventral hernia with gangrene
551.29
Ventral hernia with gangrene, other
552.20–552.21
Ventral hernia with obstruction
552.29
Ventral hernia with obstruction, other
553.20–553.21
Ventral hernia
553.29
Ventral hernia, other
701.9
Chronic ulcer of unspecified site
707.8
Chronic ulcer of other specified site
729.30
Panniculitis, unspecified site
729.39
Panniculitis, unspecified, other site
Group 3
Medicare is establishing the following limited coverage for reconstructive breast Surgery (CPT codes 19316, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396):
Covered for:
174.0–174.6
Malignant neoplasm of female breast
174.8–174.9
Other specified sites of female breast
175.0
Malignant neoplasm of male breast, nipple and areola
175.9
Malignant neoplasm of male breast, other and unspecified sites of male breast
198.2
Secondary malignant neoplasm of other specified sites, skin
198.81
Other specified sites, breast
217
Benign neoplasm of breast
232.5
Carcinoma in situ of skin, skin of trunk, except scrotum
233.0
Carcinoma in situ of breast and genitourinary system, breast
238.3
Neoplasm of uncertain behavior of other and unspecified sites and tissues, breast
239.3
Neoplasms of unspecified nature, breast
611.83
Other specified disorders of breast, capsular contracture of breast implant
612.0-612.1
Deformity and disproportion of reconstructed breast
996.54
Mechanical complication of other specified prosthetic device, implant and graft, due to breast prosthesis
V10.3
Breast
V43.82
Other organ or tissue, breast
V52.4
Fitting and adjustment of prosthetic device and implant, breast prosthesis and implant
V58.42
Other aftercare following surgery, aftercare following surgery for neoplasm
Group 4
Medicare is establishing the following dual-diagnosis limited coverage for reduction mammoplasty (CPT code 19318):
Covered for primary diagnosis:
611.1
Other disorders of breast, hypertrophy of breast
Covered for secondary diagnoses:
612.1
Deformity and disproportion of reconstructed breast, disproportion of reconstructed breast
695.89
Other specified erythematous conditions, other
719.41
Pain in joint, shoulder region
723.1
Other disorders of cervical region, cervicalgia
724.1
Spinal stenosis, other than cervical, pain in thoracic spine
724.5
Spinal stenosis, other than cervical, backache, unspecified
782.1
Symptoms involving skin and other integumentary tissue, rash and other nonspecific skin eruption
V58.42*
Other aftercare following surgery, aftercare following surgery for neoplasm
*Note: Use V58.42 to indicate a mammoplasty to reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery.
Group 5
Medicare is establishing the following limited coverage for rhinoplasty (CPT codes 30400, 30410, 30420, 30430, 30435, 30450, 30460 and 30462):
Covered for:
160.0
Malignant neoplasm of nasal cavities, middle ear and accessory sinuses, nasal cavities
170.0
Malignant neoplasm of bone and articular cartilage, bones of skull and face, except mandible
172.3
Malignant melanoma of skin, other and unspecified parts of face
173.3
Other malignant neoplasm of skin, skin of other and unspecified parts of face
195.0
Malignant neoplasm of other and ill-defined sites, head, face and neck
212.0
Benign neoplasm of respiratory and intrathoracic organs, nasal cavities, middle ear, and accessory sinuses
213.0
Benign neoplasm of bone and articular cartilage, bones of skull and face
216.3
Benign neoplasm of skin, skin of other and unspecified parts of face
232.3
Carcinoma in situ of skin, skin of other and unspecified parts of face
470
Deviated nasal septum
473.0–473.3
Chronic sinusitis
473.8–473.9
Chronic sinusitis
478.19
Other diseases of nasal cavity and sinuses
749.00–749.04
Cleft palate
749.10–749.14
Cleft lip
749.20–749.25
Cleft palate with cleft lip
754.0
Certain congenital musculoskeletal deformities of skull, face, and jaw
802.0–802.1
Fracture of face bones
Group 6
The CPT/HCPCS codes included in Group 6 requires reporting three appropriate diagnoses. Report the primary diagnosis as 272.6 (Lipodystrophy). Report a secondary diagnosis from Table 1 and a tertiary diagnosis from Table 2 below. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered.
Medicare is establishing the following limited coverage for Dermal injections (HCPCS Codes C9800, G0429, Q2026 and Q2027):
Table 1: Secondary Diagnosis:
Covered for:
042
Human immunodeficiency virus (HIV) disease
Table 2: Tertiary Diagnosis
Covered for:
309.1
Prolonged depressive reaction
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
The following ICD-9-CM codes are non-covered when billed with any CPT/HCPCS or ICD-9-CM procedure code, not just those included in this LCD:
V50.0
Elective surgery for purposes other than remedying health states, hair transplant
V50.1
Elective surgery for purposes other than remedying health states, other plastic surgery for unacceptable cosmetic appearance
V50.3
Elective surgery for purposes other than remedying health states, ear piercing
V50.8
Elective surgery for purposes other than remedying health states, other
V50.9
Elective surgery for purposes other than remedying health states, unspecified
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
For all procedures:
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
For mammoplasty:
The beneficiary’s medical record must contain, and be available for review on request, the following information:
Height and weight.
Clinical evaluation of the signs and/or symptoms ascribed to the macromastia, therapies prior to reduction mammoplasty and the responses to these therapies.
The operative report with documentation of the weight of tissue removed from each breast, obtained in the operating room.
The pathology report of the tissue removed from each breast.
For abdominal lipectomy/panniculectomy:
The beneficiary’s medical record must contain, and be available for review on request, the following information:
Description of the pannus and the underlying skin.
Description of conservative treatment undertaken and its results.
For dermal injection:
The beneficiary’s medical record must contain, and be available for review on request, the following information:
Conclusive evidence of the diagnosis of HIV and treatment with Highly Active Antiretroviral Therapy (HAART).
Description of facial abnormalities consistent with FLS.
Description of depressive symptoms and any treatments undertaken.