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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say A. According to the American Society of Plastic and Reconstructive Surgeons, the specialty of plastic surgery includes reconstructive and cosmetic procedures: 1. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. 2. Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem. Per the Medicare Benefit Policy Manual cosmetic surgery or expenses incurred in connection with such surgery, for the sole purpose of improving one's appearance, is not covered. B. Indications for specific surgical procedures: 1. Breast reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is covered. 2. Removal or revision of a breast implant is considered medically necessary when it is removed for one of the following reasons: a. Mechanical complication of breast prosthesis; including rupture or failed implant, and/or implant extrusion. b. Infection or inflammatory reaction due to a breast prosthesis; including infected breast implant, or rejection of breast implants. c. Other complication of internal breast implant; including siliconoma, granuloma, interference with diagnosis of breast cancer, and/or painful capsular contracture with disfigurement. 3. Breast Reduction is the surgical reshaping of the breasts to reduce or lift enlarged or sagging breasts. Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit.
Macromastia (breast hypertrophy) is an increase in the volume and weight of breast tissue relative to the general body habitus. Breast hypertrophy may adversely affect other body systems: musculoskeletal, respiratory, and integumentary. Unilateral hypertrophy may result in symptoms following contralateral mastectomy. Medical necessity for a breast reduction 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, and To reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery. Non-surgical interventions preceding breast reduction 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. A medically reasonable and necessary breast reduction could be indicated in the presence of significantly enlarged breasts and the presence of at least one of the following signs and/or symptoms: a. Back, neck or shoulder pain from macromastia and unrelieved by 6 months of: Conservative analgesia, Supportive measures (garment, etc.), Physical Therapy, or b. Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity, or c. Intertriginous maceration or infection of the inframammary skin refractory related to dermatologic measures. d. Permanent shoulder grooving with skin irritation by supporting garment (bra strap). The amount of breast tissue to be removed must be proportional to the body surface area (BSA) per the Schnur scale below. If only one breast meets the Schnur scale criteria; breast tissue may be removed from the other breast in order to achieve symmetry. You can find this information in Medicare's Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L34698). The rules say Blepharoplasty, blepharoptosis and lid reconstruction may be defined as any eyelid surgery that improves abnormal function, reconstructs deformities, or enhances appearance. They may be either functional/reconstructive or cosmetic. Upper blepharoplasty (removal of upper eyelid skin) and/or repair of blepharoptosis should be considered functional/reconstructive in nature when the upper lid position or overhanging skin or brow is sufficiently low to produce functional complaints, usually related to visual field impairment whether in primary gaze or down-gaze reading position. Upper blepharoplasty may also be indicated for chronic dermatitis due to redundant skin. Another indication for blepharoptosis surgery is patients with an anophthalmic socket experiencing ptosis or prosthesis difficulties. Brow ptosis (i.e., descent or droop of the eyebrows) can also produce or contribute to functional impairment.
The criteria in section A (patient signs and symptoms), and section B (visual field) below must be documented to demonstrate medical necessity. A. Documentation in the medical records must include patient complaints and findings secondary to eyelid or brow malposition such as: Interference with vision or visual field, related to activities such as, difficulty reading due to upper eyelid drooping, looking through the eyelashes, seeing the upper eyelid skin, or brow fatigue. Chronic eyelid dermatitis due to redundant skin. Difficulty wearing prosthesis, artificial eye. Margin reflex distance (MRD) of 2.5 mm or less. (The margin reflex distance is a measurement from the corneal light reflex to the upper eyelid margin with the brows relaxed.) A palpebral fissure height on down-gaze of 1 mm or less. (The down-gaze palpebral fissure height is measured with the patient fixating on an object in down-gaze with the ipsilateral brow relaxed and the contralateral lid elevated.) The presence of Herring's effect meeting one of the above two (#4 or 5) criteria. (Herring's law is one of equal innervation to both upper eyelids and is considered in the documentation to perform bilateral ptosis in which the position of one upper eyelid has marginal criteria and the other eyelid has good supportive documentation for ptosis surgery. In these cases, the surgeon can lift the more ptotic lid with tape or instillation of Phenylephrine drops into the superior fornix. If the less ptotic lid then drops downward according to Herring's law to the point of an MRD of 2.5 mm or less or a down-gaze MRD of 1.5 or less or a palpebral fissure width on down-gaze of 1 mm or less, then the less ptotic lid would be considered for surgical correction.) B. Visual fields
The indication for surgery is supported if a difference of 12 or more or 30% superior visual field difference is demonstrated between visual field testing before and after manual elevation of the eyelids. Visually significant brow ptosis may be documented by visual field testing with the brow elevated demonstrating a difference of 12 or more or 30% superior visual field difference. Visual fields need to meet accepted quality standards, whether they are performed by the Goldmann perimeter technique or by use of a standardized automated perimetry technique. Visual fields are not necessary for patients with an anophtholmic socket who is experiencing ptosis of difficulty with their prosthesis. C. Relief of eye symptoms associated with blepharospasm. Primary essential idiopathic blepharospasm is characterized by severe squinting, secondary to uncontrollable spasms of the periorbital muscles. Occasionally, it can be debilitating. If other treatments have failed or are contraindicated (i.e., an injection of Botulinum Toxin A,) an extended blepharoplasty with wide resection of the orbicularis oculi muscle complex may be necessary. (See Botulinum Toxin Type A and Type B, L34635). You can find this information in Medicare's Local Coverage Determination (LCD): Blepharoplasty, Blepharoptosis and Brow Lift (L34528).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The health plan contract says cosmetic surgery or procedures: Covered in cases of an accidental injury or for improvement of the functioning of a malformed body member. Covered for all stages of reconstruction for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance. You can find this information in Chapter 4 on page 86 of the plan's 2021 Evidence of Coverage.