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Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.
The coverage eligibility of medical and surgical therapies to treat musculoskeletal abnormalities and abnormalities of the integumentary system (i.e., the skin, subcutaneous and accessory structures including the breast) are often based on a determination of whether the abnormality is considered reconstructive or cosmetic in nature. While reconstructive is often taken to mean that the service “returns the patient to whole” and cosmetic is often interpreted as meaning the restoration of appearance only, the application of these terms must be based on specific contract language, which often varies significantly from the above definitions. The following general principles describe the issues to be determined in properly administering the contract language.
1. The eligibility of a service for coverage may be based upon either a specific benefit addressing cosmetic or reconstructive services or upon its specific exemption from an exclusion for cosmetic or reconstructive services or both.
2. The definition of reconstructive may be based on two distinct factors: 1) whether the service is primarily indicated to improve or correct a functional impairment or is primarily to improve appearance; and 2) what the etiology of the defect is (e.g., congenital anomaly, anatomic variant, post-traumatic, post-therapeutic intervention, disease process). Therapeutic interventions include, but are not limited to, surgery, radiation, and chemotherapy. Cosmetic services are usually considered to be those that are primarily to restore appearance and that otherwise do not meet the definition of reconstructive or those whose etiology is not exempted from the definition of cosmetic.
3. In many instances the concept of reconstructive overlaps with the concept of medically necessity. For example, services intended to correct a functional impairment may also be considered medically necessary and thus eligible for coverage, regardless of the contract language pertaining to reconstructive services, unless some other exclusion applies.
4. As the above point suggests, the presence or absence of a functional impairment is a critical point in interpreting coverage eligibility. For musculoskeletal conditions, the concept of a functional impairment is straightforward. However, when considering dermatologic conditions, the function of the skin is more difficult to define. Procedures designed to enhance the appearance of the skin are typically considered cosmetic, but some dermatologic conditions may significantly alter the function of the skin; one example is pemphigus, which impairs the fluid balance of the body. In addition, some Plans may have separate contract language or medical policies that address specific dermatologic conditions, such as port wine stains or acne, and that may supersede their cosmetic/reconstructive contract language or medical policy.
5. The definition of reconstructive services may also include those services designed to restore the normal appearance of the patient, regardless of whether a functional impairment is present. Breast reconstructive surgery after a medically necessary mastectomy, or revision of burn scars in noncritical areas are common examples. The determination of coverage eligibility typically depends on the etiology of the condition. For example, the cosmetic exclusion may include “all services primarily to improve appearance, except those due to prior trauma or therapeutic interventions.” Another example would be a reconstructive benefit that specifies that reconstructive services are “those services provided to improve or restore function or to correct defects due to congenital anomalies, prior trauma, prior therapeutic procedures or disease.” The use of “or” allows coverage of conditions due to those etiologies without the requirement for a functional impairment. This would support a concept of reconstructive services as returning the patient to “whole” after surgery or trauma, or the other etiologies listed above.
Categories of conditions that may be included as part of the contractual definition of reconstructive services include the following:
- accidental trauma or injury
- congenital anomalies
- anatomic variants
The final determination of eligibility for coverage should be based on application of the specific contract language based on a determination of the etiology of the defect and the presence or absence of documented functional impairment.
Determinations of whether a proposed therapy would be considered reconstructive or cosmetic should always be interpreted in the context of the specific benefits language.
The requirement of the presence of a functional impairment as a coverage criterion for a specific etiology may vary from plan to plan, particularly as applied to dermatologic conditions. Some plans may have separate policies for certain dermatologic conditions, such as acne or port wine stains, which supersede generic language describing cosmetic and reconstructive procedures. However, it should be noted that, in general, the presence of a functional impairment would render its treatment medically necessary and thus not subject to contractual definitions of reconstructive or cosmetic.
No applicable information
BlueCard/National Account Issues
Contract language may vary regarding the definition of reconstructive services for different categories of conditions. Two key questions must be asked. First, it must be determined whether a functional impairment is present that would render its treatment medically necessary, and thus eligible for coverage if no other exclusions apply. If no functional impairment is present, the etiology of the condition must be determined and the contract language reviewed to see if this etiology is included in the definition of reconstructive services. The following grid may be filled in as a guide to interpreting benefits language.
|1. Is a functional impairment present?*||2. If no functional impairment is present, is the condition included in definition of reconstructive services?|
|Accident or Injury|
* If a functional impairment is present, the treatment may be considered medically necessary.
The following examples are provided for further illustration of the concepts.
1. A child is born with a pectus excavatum and the parents are seeking coverage for surgical correction. No functional impairment is documented, i.e., there are no cardiac or respiratory problems and thus surgical correction is considered ineligible for coverage under the concept of medically necessity. Therefore, the contract language is examined to determine whether treatment of this congenital anomaly would be considered reconstructive and thus covered. The contract for this specific plan reads, “Reconstructive therapies are any medical or surgical services designed to restore (normal) bodily appearance that has been altered due to either surgery, trauma, accident or injury.” Since the definition of reconstructive surgery does not include congenital anomalies and since no functional impairment is present that would render treatment medically necessary, it is determined that according to this contract language, surgery for pectus excavatum would be considered cosmetic and thus ineligible for coverage.
2. Two men covered under different plans are seeking treatment of rhinophyma. Since there is no functional impairment associated with rhinophyma, its treatment is considered ineligible for coverage on the basis of medical necessity. Therefore, similar to the above case, the contract language is reviewed to determine whether such treatment would be considered eligible for coverage according to the definition of reconstructive services. In the first man, the benefits language reads, “Reconstructive therapies are any medical or surgical services designed to restore bodily appearance that has been altered due to either disease, trauma, surgery, accident or injury.” Since the definition of reconstructive surgery includes diseases, treatment of rhinophyma is considered eligible for coverage. In contrast, the benefits language of the second man reads as follows, “Reconstructive therapies are any medical or surgical services designed to restore bodily appearance that has been altered due to either surgery, trauma, accident or injury.” Since diseases are not included in this definition and since no functional impairment is associated with rhinophyma that would render the treatment medically necessary, according to this contract treatment of rhinophyma is considered cosmetic and thus ineligible for coverage.
No applicable information
|7/10/98||Add to Administration section||New policy|
|7/12/02||Replace policy||Policy reviewed without literature review; new review date only|
|10/9/03||Replace policy||Policy reviewed by consensus without literature review; no changes in policy; no further review scheduled|