1. According to the American Society of Plastic and Reconstructive Surgeons, the specialty of plastic surgery includes reconstructive and cosmetic procedures: 

**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, may also be done to approximate a normal appearance, and may be
covered as surgery is considered reconstructive in nature.

**Cosmetic surgery** is performed to reshape normal structures of the body in
order to improve the patient's appearance and self-esteem. Please refer to CMS
IOM Publication 100-02, _Medicare Benefit Policy Manual_ , Chapter 16: Section
120 for detailed information.

    * 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 (e.g. but not limited to severe burns or repair of the face following a serious automobile accident) as to merit consideration for corrective surgery.
    * Treatment of complications arising from **cosmetic** surgery will be considered reasonable and necessary as long as infection, hemorrhage or other serious documented medical complication occurs, and the beneficiary has been officially discharged from the facility.

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.

  2. Indications for specific surgical procedure

    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 whether placed for reconstructive or cosmetic reasons, is considered medically necessary when it is removed for one of the following reasons:26
      1. Mechanical complication of breast prosthesis; including rupture or failed implant, and/or implant extrusion.
      2. Infection or inflammatory reaction due to a breast prosthesis; including infected breast implant, or rejection of breast implants.
      3. 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,
      * To improve or correct asymmetry following cancer surgery on one breast. 

**Note:** either the involved breast or contralateral breast may be treated to
achieve symmetry.  
 **Note:** For coverage indications for contralateral reconstruction of an
unaffected breast following a medically necessary mastectomy, refer to the CMS
Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations
Manual, Chapter 1, Part 2, 140.2.

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:

      * Back, neck or shoulder pain from macromastia and unrelieved by 6 months of:  
\- Conservative analgesia,  
\- Supportive measures (garment, etc.),  
\- Physical Therapy, or

      * Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity, or
      * Intertriginous maceration or infection of the inframammary skin refractory related to dermatologic measures.
      * 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 Schnur18 scale below. If the individual's body
surface area and weight of breast tissue removed fall above the 22nd
percentile, then the surgery is considered medically reasonable and necessary
with the appropriate criteria. If only one breast meets the Schnur scale
criteria; breast tissue may be removed from the other breast in order to
achieve symmetry.

**Schnur Scale:**

**Body Surface**  
 **Area (m2)** | **Average grams of tissue per breast to  
be removed**  
---|---  
1.40-1.50 | 218-260  
1.51-1.60 | 261-310  
1.61-1.70 | 311-370  
1.71-1.80 | 371-441  
1.81-1.90 | 442-527  
1.91-2.00 | 528-628  
2.01-2.10 | 629-750  
2.11-2.20 | 751-895  
2.21-2.30 | 896-1068  
2.31-2.40 | 1069-1275  
2.41-2.50 | 1276-1522  
2.51-2.60 | 1523-1806  
2.61-2.70 | 1807-2154  
2.71-2.80 | 2155-2568  
2.81-2.90 | 2569-3061  
2.91-3.00 | 3062-3650  
    4. Mastectomy for gynecomastia  
Gynecomastia is the excessive growth of the male mammary glands. These
conditions can cause significant clinical manifestations when the excessive
breast weight adversely affects the supporting structures of the shoulders,
neck, and trunk.

Mastectomy with nipple preservation or reduction mammoplasty is considered
reconstructive and a covered service for males with gynecomastia Grade III and
IV or abnormal breast development with redundancy.

      * Persists more than 3 to 4 months after the pathological causes are ruled out (e.g. not limited to testosterone deficiency, testicular tumor, liver disease, or drug induced).34
      * Persists after 3 to 4 months of unsuccessful medical treatment for pathological gynecomastia.16
      * Pain or tenderness directly related to the breast tissue which has a clinically significant impact upon activities of daily living.
      * Clinical symptoms refractory to a trial of analgesics or anti-inflammatory agents.
      * For significant clinical manifestations when the excessive breast weight adversely affects the supporting structures of the shoulders, neck and trunk.

American Society of Plastic Surgeons' gynecomastia scale:16

      * Grade I: Small breast enlargement with localized button of tissue that is concentrated around the areola.
      * Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest.
      * Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present.
      * Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast
    5. Gigantomastia of Pregnancy  
Medicare considers subtotal mastectomy or reduction mammoplasty for the
unusual condition of Gigantomastia of Pregnancy accompanied by any of the
following complications (and delivery is not imminent) medically reasonable
and necessary when signs or symptoms are refractory to medical treatment or
physical interventions have not adequately alleviated symptoms such as:

      * Massive infection
      * Significant hemorrhage
      * Tissue necrosis with slough
      * Ulceration of breast tissue
      * Intertriginous maceration or infection of the inframammary skin refractory to dermatologic measures.
    6. Tattooing   
To correct color defects of the skin may be considered reconstructive when
performed in connection with a payable post-mastectomy reconstruction, or for
reconstruction following trauma or removal of cancer from an eyelid, eyebrow
or lip(s).

    7. Punch graft hair transplant may be considered reconstructive when it is performed for eyebrow(s) or symmetric hairline replacement following a burn injury, trauma or tumor removal.

Nasal surgery is defined as any procedure performed on the external or
internal structures of the nose, septum or turbinate. 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
or symptoms.

Rhinoplasty is a procedure that changes the shape or appearance of the nose
while improving or preserving the nasal airway. The primary purpose for
Rhinoplasty can be functional, aesthetic, or both and may include other
procedures on the paranasal sinuses, septum, or turbinates.13

Septoplasty is a procedure used to correct deformities of the nasal septum
which can often cause issues with airflow and difficulty breathing.23

    8. a) Rhinoplasty is considered medically reasonable and necessary when the procedure is performed for correction and repair of any of the following indications:

      * Secondary to trauma, disease, congenital defect with nasal airway obstruction that has not resolved after previous septoplasty/turbinectomy or would not be expected to resolve with septoplasty/turbinectomy alone.19
      * chronic, non-septal, nasal obstruction due to vestibular stenosis (i.e., collapsed internal valves).
      * nasal deformity secondary to a cleft lip/palate or other congenital craniofacial deformity causing a functional impairment. (e.g., cleft lip nasal deformities, choanal atresia, oronasal or oromaxillary fistula)13

b.) Septoplasty is considered medically necessary when performed for any of
the following indications:

      * septal deviation/deformity causing nasal airway obstruction that has proved unresponsive to a trial of conservative medical management lasting at least 6 weeks (e.g. topical nasal corticosteroids, decongestants, antibiotic, allergy evaluation and therapy, etc.).22, 23
      * recurrent sinusitis (4 or more episodes in a year) secondary to a deviated septum that does not resolve after appropriate medical and antibiotic therapy., 20, 23
      * recurrent epistaxis (4 or more significant episodes) related to a septal deformity.20
      * asymptomatic septal deformity that prevents access to other trans nasal areas when such access is required to perform medically necessary procedures (e.g., ethmoidectomy).
      * performed in association with cleft lip or cleft palate repair.21
      * 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.14
    9. Chemical Peel  
Is covered for the treatment of Actinic Keratosis.

    10. Dermabrasion is considered medical reasonable and necessary when correcting defects resulting from traumatic injury, surgery or disease.

Dermabrasion, segmental, face in conjunction with antimicrobial therapy is
covered for the treatment of rhinophyma. Rhinophyma is characterized by skin
thickening, which can cause an enlargement of the nose due to excess tissue
and overgrowth of sebaceous glands.7 Rhinophyma in its most severe cases can
affect breathing and even vision.3,7

    11. Dermal injections for facial lipodystrophy syndrome (LDS) using dermal fillers approved by the FDA for this purpose, and then only in human immunodeficiency virus (HIV)-infected Medicare beneficiaries who manifest depression secondary to the physical stigma of HIV treatment will be covered. Effective for claims with dates of service on and after March 23, 2010.

      * See Pub. 100-03, _Medicare National Coverage Determinations_ Chapter 1, Coverage Determinations Part 4, Section 250.5 Dermal Injection for the Treatment of Facial Lipodystrophy Syndrome.
      * See Pub. 100-04, _Claims Processing Manual_ , Chapter 32, Section 260, Dermal Injection for the Treatment of Facial Lipodystrophy Syndrome.
    12. Abdominal Lipectomy/Panniculectomy

      * Panniculectomy will be considered medically necessary when the pannus or panniculus hangs below the level of the pubis, and the 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 or remains refractory to appropriate medical therapy (e.g., topical antifungals, corticosteroids, antibiotics)] over a period of 3 months.12
      * When surgery is performed to alleviate such complicating factors as inability to walk normally due to pannus size, 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.12
      * This procedure may also be medically necessary for the patient that has had a significant weight-loss following the treatment of morbid obesity, in addition to meeting the criteria noted above, there should be evidence that the individual has maintained a stable weight for at least 6 months. If the weight loss is the result of bariatric surgery, abdominoplasty/panniculectomy should not be performed until at least 18 months after bariatric surgery and only when weight has been stable for at least the most recent 6 months and infection and inflammation has continued for the most recent 3 months.12
  3. The following procedures are non-covered for the following indications.

**Limitations**

    1. Cosmetic surgery performed to treat psychiatric or emotional problems is not covered.

    2. 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.

    3. Dermabrasion

      * Post-acne scarring
      * Rosacea other than rhinophyma
      * All other indications not identified as covered in the section above
    4. Abdominal Lipectomy/Panniculectomy

      * Repairing abdominal wall laxity, or diastasis recti
      * Redundancies resulting from weight loss or weight loss surgery when that tissue is without evidence of chronic infection or inflammation that is refractory to conservative treatment as outlines in the indications listed above.
      * Solely to improve appearance
      * All other indications unless covered in the section above

**Note:** Abdominal Lipectomy/Panniculectomy is considered experimental and
investigational for minimizing the risk of hernia formation or recurrence.
There is no 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.

    5. Liposuction used for body contouring, weight reduction or the harvest of fat tissue for transfer to another body region for alteration of appearance or self-image or physical appearance is considered cosmetic and not covered as medically necessary.

    6. Reconstructive Breast Surgery: Removal of Breast Implants for re-implantation of an implant inserted for cosmetic purposes only and not for history of mastectomy for treatment of breast cancer, lumpectomy, or treatment of contralateral breast to bring it into symmetry with a reconstructed breast following cancer surgery is not a covered Medicare benefit.

    7. Reduction Mammaplasty 
      * Surgery performed primarily to reshape the breasts to improve appearance or self-image.
      * Mammapexy unrelated to breast reconstruction following a medically necessary mastectomy.
    8. Mastectomy for gynecomastia

      * Breast reduction or surgical mastectomy for gynecomastia, either unilateral or bilateral, as the first line treatment.
      * When performed solely to improve appearance of the male breast or to alter contours of the chest wall.
    9. Gigantomastia of Pregnancy

      * Surgery to reshape the breasts to improve appearance or self-image.
      * All other indications not identified as covered in the section above.
    10. 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. These situations will be handled through the appeal process.

    11. Thyroid chrondoplasty to alter the appearance of the thyroid cartilage which is without functional defect is considered cosmetic.

    12. Rhinoplasty is not covered 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 or improving self-image in the absence of any signs or symptoms of functional abnormalities.
      * As a primary treatment for an obstructive sleep disorder when the above criteria for approval have not been met.
    13. Rhytidectomy is generally considered a cosmetic procedure. It may be considered medically necessary upon review to correct a functional impairment as a result of a disease state ie; facial paralysis. Often this procedure is performed in conjunction with other procedures to correct the impairment.

The American Society of Plastic Surgeons explains Plastic Surgery can include
both reconstructive and cosmetic procedures.1 Typically reconstructive surgery
is considered medically necessary to restore function and normal appearance,
and to correct deformities that are congenital, trauma related or created by
medical conditions such as cancer. Cosmetic surgery is not considered
medically necessary as it is performed to reshape and adjust normal anatomy to
enhance appearance. Certain conditions can be considered either reconstructive
or cosmetic depending on the patient's specific situation. An example of this
is rhinoplasty which may be performed to enhance the person's appearance which
is cosmetic but also may be necessary to restore normal breathing and
appearance after a trauma such as a fracture which is reconstructive. Often
rhinoplasty is performed with other procedures which involve the nasal septum,
nasal valve, nasal turbinates, or the paranasal sinuses. When adjunctive
procedures are performed that do not change the nasal shape or appearance,
they do not meet the definition of rhinoplasty. Rhinoplasty performed to
address functional abnormalities may inadvertently change the shape or
appearance of the nose.

**Rhinoplasty/Septoplasty**

Ishii et al13 created clinical guidelines to provide evidence-based
recommendations for the treatment of patients who are candidates for
rhinoplasty. Rhinoplasty ranks among the most commonly performed cosmetic
surgery in the United States. Rhinoplasty should be considered more than just
for cosmetic reasons as it is often medically necessary to improve nasal
respiration and relieve any congenital or acquired airway obstructions. While
Rhinoplasty may be performed to address a functional abnormality, it may also
change or enhance the appearance of the nose. Rhinoplasty is often performed
with adjunctive procedures that involve the nasal septum, nasal valve, nasal
turbinates, or the paranasal sinuses. When these accompanying procedures are
performed without an impact on the nasal shape or appearance, they do not meet
the definition of Rhinoplasty.  
  
These guidelines were created by a Guideline Development Group that consisted
of 16 members representing experts in plastic surgery, facial plastic and
reconstructive surgery, otolaryngology, otology, rhinology, sleep medicine,
psychiatric, advanced practice nursing, and consumer advocacy. Three
literature searches were performed from May 2015 through December 2015 to
identify clinical practice guidelines, systematic reviews, and randomized
controlled trials. After all exclusion methods the literature resulted in 1
guideline, 22 systematic reviews, and 19 randomized controlled trials. This
information was used to gather evidence, relevant treatments, and outcomes.

There were 10 evidence-based recommendations created based on Grade B and C
quality of evidence with overall prevalence of benefit over harm. (1)
Clinicians should ask all patients about their motivation for surgery and
expectations and outcomes. (2) Candidates should be assessed for comorbid
conditions that could impact surgery. (3) The rhinoplasty candidate should be
evaluated for nasal airway obstruction during the preoperative assessment. (4)
Candidates should be educated regarding what to expect after surgery and any
potential complications. (5) Candidates should be counseled about the impact
of surgery on nasal airway obstruction and how sleep apnea might affect
perioperative management. (6) The patient should be educated about strategies
to manage pain and discomfort after surgery. (7) Perioperative antibiotics for
rhinoplasty should not be routinely prescribed for more than 24 hours after
surgery. (8) Perioperative systemic steroids have the option to be
administered to the rhinoplasty patient. (9) Packing should not be routinely
used in the nasal cavity of rhinoplasty patients at the conclusion of surgery.
(10) Clinicians should document patient satisfaction with nasal appearance and
function at a minimum of 12 months after surgery.

Included within this guideline were validated patient-outcome tools used to
perform functional assessments for rhinoplasty. These tools included Nasal
Obstruction Septoplasty Effectiveness (NOSE) scale and Sino-Nasal Outcome Test
(SNOT-22). Useful tools for evaluating the nasal septums and turbinates
preoperatively included anterior rhinoscopy, nasal endoscopy, Cottle maneuver
and modified Cottle maneuver. Anterior rhinoscopy is helpful for assessing the
nasal septum and turbinates. For patient with no obvious cause for nasal
obstruction using anterior rhinoscopy, nasal endoscopy can be valuable. Nasal
endoscopy can be useful to evaluate the posterior septum, the ostiomeatel
complex, any possible nasal polyps or purulent drainage, the posterior
choanae, adenoidal hypertrophy, and the existence of any tumors. Static and
dynamic inspection, palpation and the modified Cottle maneuver can be used to
supplement physical examination for evaluating the internal nasal valve and
external nasal valve for nasal valve collapse. For evaluating the extent of
septal deviation, turbinate hypertrophy, and nasal deformity, imaging studies
are not useful and should not be performed.

Simon and Sidle19 performed a literature review of surgical procedures used
for augmenting the nasal airway. For patients presenting to otolaryngology
clinics, the most common complaint is nasal obstruction. There are many
different anatomical factors that can contribute to these obstructions and the
feeling of decreased nasal airflow. Nasal septum deviation secondary to
congenital, traumatic, or iatrogenic etiologies was the most common finding in
patients with complaints of nasal obstructions. These authors too found that
the NOSE scale or SNOT-22 test should be used to identify the patient's
complaint. The preoperative assessment ought to include anterior rhinoscopy
for evaluating septal deviation, nasal endoscopy for any possible tumors,
Cottle maneuvers and external dilators to assess and determine dynamic valve
collapse and also trials of decongestants for evaluating if mucosal congestion
is contributing to the nasal obstruction. There are several procedures used to
improve these obstructions that fall under the functional rhinoplasty
technique such as but not limited to Septoplasty, extracorporeal Septoplasty,
and correction of caudal septal deviation.  
  
Han et al23 developed a clinical consensus statement (CCS) in regards to
septoplasty with or without inferior turbinate reduction. A panel was
assembled of experts in otolaryngology who performed a systematic literature
review to obtain important evidence to support the diagnosis, medical and
surgical management of Septoplasty with or without inferior turbinate
reduction. A deviated septum is one of the common reasons for nasal
obstruction and may or may not involve hypertrophic inferior turbinates.
Septoplasty and inferior turbinate reduction aim to improve the nasal airway
in these cases. Septoplasty is also used as a supporting procedure to improve
access and the function of the paranasal sinuses.

The authors noted that there were no clinical guidelines in regard to
appropriate methods for diagnoses and treatment of nasal obstruction secondary
to septal deviation and turbinate hypertrophy. Payers often require tests such
as acoustic rhinometry/rhinomanometry, nasal endoscopy, photos, and imaging
despite evidence-based literature prior to approving payment for septoplasty.
The panel developed the CCS after evaluating the appropriateness of
septoplasty with or without inferior turbinate reduction based on (1)
systematic literature review; (2) establishment of active definitions of
septoplasty and inferior turbinoplasty, intended scope of practice, and
interested people for the consensus statement; (3) modified Delphi survey
development and completion; (4) revising clinical statement repeatedly based
on survey results; and (5) assembling data, analysis, and presentation.

The panel reached an agreement that nasal septoplasty is defined as a
procedure used to correct a deviated nasal septum to improve nasal function,
form, or both. Determining patients appropriate for septoplasty is based on
symptomology and physical examination. The panel reached a strong consensus
that anterior rhinoscopy, nasal endoscopy or both are adequate to determine
septal deviation and can provide useful information prior to septoplasty. The
panel did not determine acoustic rhinometry or rhinomanometry to be helpful in
diagnosing septal deviation but can be helpful for patients whose primary
issue is nasal obstruction. The panel agreed that photographic evidence is
unneeded to confirm septal deviation. The group also determined a nasal
steroid trial for 4 weeks prior to septoplasty was adequate conservative
treatment.

Kaufman et al21 performed a literature review regarding various modalities for
achieving a successful rhinoplasty for patient with cleft nasal deformity. The
cleft nasal deformity presents as a difficult challenge in plastic surgery as
it involves skin, mucosa, cartilage, and skeletal platform. Cleft lip nasal
surgery can be divided into primary, intermediate, and secondary repairs.
Early intervention can be beneficial for an earlier restoration of nasal shape
with the increased chance for more symmetrical nasal growth. The primary
rhinoplasty is performed with the intention to restore symmetry and reposition
nasal structures so that deformities will not be exacerbated by further
growth. Some patients may need to have intermediate rhinoplasty before
reaching school age in order to achieve greater symmetry and to help avoid
further growth deformities. The best approach for a secondary rhinoplasty
surgery is to wait until basal growth is completed. The deformity is complex
and should be addressed during multiple stages of the patient's life to assist
in reaching the best outcome.

Modica and colleagues14 conducted a study on a sample of 52 patients all
followed by the Otolaryngology Unit of the University Palermo between January
2015 and January 2017. The purpose of the study was to determine if functional
nasal surgery was effective in moderate to severe OSAS on improving CPAP
compliance. The patients in the study all underwent different nasal surgeries
(septoplasty, unblocking of lower turbinates, and FESS) and were evaluated 6
months after the surgery using the NOSE scale and evaluating CPAP usage. Most
patients following surgery reported an improvement in the degree of
obstruction to mild. The results showed by improving nasal function, CPAP
usage increased from 2-3 hours a night to 6-8 hours a night with a reduction
in CPAP pressure.

**Reconstructive Breast Surgery: Removal of Breast Implants**

The Food and Drug Administration (FDA)26 reviewed the risks of breast implants
and the associated complications and adverse outcomes. The life of the
implants and the chances of developing complications vary by person. Some of
the complications listed by the FDA are breast pain and changes in sensation,
scar tissue that can cause capsular contracture, rupture and deflation of the
breast implant, and the development of different kinds of cancer such as non-
Hodgkins lymphoma or breast cancer, systemic symptoms, infections, or
connective tissue diseases.

**Breast Reduction**

The American Society of Plastic Surgeons (ASPS)9 notes female symptomatic
breast hypertrophy has not only negative psychosocial indications but negative
physical indications as well.9 Clinical guidelines were developed based on the
evidence in 667 articles to support reduction mammoplasty for symptomatic
breast hypertrophy. Symptomatic breast hypertrophy causes persistent neck and
shoulder pain, grooving from brassiere straps that is painful, chronic rashes
in the skin folds of the breast, and/or frequent headaches, backaches, and
upper extremity peripheral neuropathies due to the increased volume and weight
of hypertrophic breast tissue. There is no treatment for female breast
hypertrophy that is long lasting and non-surgical. Orthotic brassieres may
offer some relief but often cause increased discomfort through pressure from
the straps. Reduction mammoplasty offers the best approach to relieving the
physical symptoms of breast hypertrophy.

Lonie and colleagues27 conducted a literature search of the PubMed and
Cochrane Library, Medline and SCOPUS databases from 1966 to July 2018
according to Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) guidelines. They included breast reduction, reduction
mammoplasty, treatment outcomes, personal satisfaction, quality of life,
questionnaire and instrument in their search terms. Pre-determined inclusion
criteria by 2 authors resulted in 95 articles that were included. The results
of the search were 95 articles met the inclusion criteria and represented
9,716 patients. Data was extracted from the included studies relating to
demographics, surgical technique, questionnaires used and physical,
psychological and aesthetic outcomes. Fifty-eight studies listed overall
satisfaction as primary endpoint, including 5,867 patients. The authors
inferred that in 90.3% of the studies, patients reported improvements in the
vast majority of premorbid symptoms both physical and mental, stating a
finding consistent with previous reviews of this subject.

**Gynecomstia**

The ASPS16 defines gynecomastia as "the presence of an abnormal proliferation
of breast tissue in males". Gynecomastia can be caused by a broad number of
reasons that are either physiological or pathological. True gynecomastia is
due to glandular breast tissue where as pseudogynecomastia the breast enlarges
secondary to fat accumulation. Both fat and glandular tissue are present in
mixed gynecomastia. During puberty gynecomastia is common but often regresses
by 6 months to within 3 years of onset. Adult gynecomastia is correlated with
increased age due to progressive underactive testicular function, increase in
body fat and growth in the estrogen/androgen ratio. Gynecomastia is graded
using a scale adapted from the McKinney and Simon, Hoffman and Kohn scale and
grade I-IV. The ASPS recommends surgical treatment of gynecomastia to
reconstruct the male chest contour and histological explanation of suspicious
breast growths. Biopsy of breast tissue is advisable when malignancy is
suspected. Surgical treatment is recommended for unilateral or bilateral grade
III or IV gynecomastia that persists more than 3 to 4 months after
pathological causes have been ruled out, after 3 to 4 months of failed medical
treatment, and for pain and discomfort due to the enlargement and tightness of
the hypertrophied breast.

**Gestational Gigantomastia**

Gestational gigantomastia is a rare condition distinguished by exaggerated,
rapid, and often disabling enlargement of the breasts.28 It most often begins
in the first trimester and generally occurs bilaterally. Rakislova and
colleagues28 noted that less than 100 cases have been reported in literature
and while it is benign, it can lead to serious complications and sometimes
death. These authors describe a case study of a 30 year old HIV-positive
female with no pertinent past medical history. The patient began having marked
increased enlargement of both breasts at 8 to 10 weeks gestation. Initially
she did not have pain but as it progressed she experienced burning pain and
noticeable discomfort. She presented to the emergency room at 24 weeks
gestation and was diagnosed with gestational gigantomastia. Surgical
intervention was not recommended due to potential complication and the patient
underwent treatment with Penicillin G for 10 days. Despite conservative
treatment the ulcers continued to increase and caused heavy blood loss. The
patient lost between 3 and 4 liters of blood. The patient received multiple
blood transfusions and despite treatment expired on the 13th hospital day.

Fletcher and colleagues29 conducted a case study on a 31 year old woman,
gravida 5, para 4. She presented at 18 weeks gestation with bilateral breast
swelling, erythema, and pain for the last 4 months. The patient was eventually
hospitalized for her worsening breast pain and after diagnosis of gestational
gigantomastia (GG) she was started on bromocriptine. Despite conservative
treatment she developed spontaneous local hemorrhage in her left breast. Due
to pain and to avoid further complications she underwent cesarean section at
term. The patient continued bromocriptine but continued to have severe
discomfort and underwent a breast reduction. GG can be significantly
debilitating. Skin ulceration, necrosis, infection and hemorrhage can occur as
well as sepsis, multiorgan failure, and death though rarely. During pregnancy,
conservative management is preferred over breast reduction due to the risk of
harm to the fetus. In cases of massive hemorrhage, ulceration, sepsis or
necrosis surgical management should be pursued by either breast reduction or
mastectomy. Due to the high chance of recurrence with future pregnancies it is
recommended those planning future pregnancies undergo mastectomy.

**Dermabrasion**

Chellappan and Castro24 presented a case study where they performed
electrocautery dermabrasion on a 62 year old male with severe rhinophyma.
Rhinophyma is the most advanced stage of rosacea and is classified as Stage
IV. During this stage the phymatous changes present with hyperplasia and/or
ocular inflammation. Phymatous tissue enlarges over a period of time and
should be treated in the early stages to prevent progression as more advanced
stages have irreversible fibrotic changes. Extensive thickening of the tissue
can obstruct external nasal valves making treatment of the rhinophyma
medically necessary to alleviate respiratory issues. Challappan and Castro24
show in this case study support of using electrocautery and dermabrasion to
remove hypertrophic skin and create a smooth contour. The patient had
significant improvement in respiratory function and the patient's skin
returned to normal pigmentation, scab free four weeks following the procedure.
This supports electrocautery dermabrasion as a mainstay of treatment allowing
smooth contouring, efficient hemostasis and does not require multiple
treatments.

Niamtu7 performed a review of the diagnosis and treatment of rhinophyma.
Rhinophyma is the end process for severe rosacea and can be a debilitating
problem both functionally and psychosocially. The most severe cases can affect
breathing and even vision. Minor or early cases can be treated using a range
of rosacea medications such as topical creams, sulfur based washes,
antibiotics, Retin-A, and light based or photodynamic therapy. Medical or drug
treatment in moderate to advanced cases is futile and surgical treatment is
certain.

Claros et al25 notes in their study that while no consensus concerning the
treatment of rhinophyma has been reached, there are many different surgical
procedures that have been proposed for the management of this disease. While
rhinophyma is considered the final stage of rosacea, it is rare in the older
population. This case study retrospectively looked at twelve cases over a 12
year period. These patients were treated with the classical dermabrasion
technique with decortication and fibrin glue was applied topically to the skin
surface. This technique promoted complete healing and patients reported
improved quality of life with no recurrence.

**Abdominal Lipectomy/Panninculectomy**

The American Society of Plastic Surgeons31 outlines practice parameters that
are focused on the surgical removal of excess skin and fat that occurs in
obsess patients or remains following massive weight loss. There are numerous
procedures and techniques developed to treat the imperfections that result
from massive weight loss such as abdominoplasty, panniculectomy,
circumferential lipectomy, torsoplasty, medial thigh lift, and breast
reduction. The operative treatment for the correction of the imperfections
will vary depending on the patient's body type, fat deposition pattern, and
the amount of weight loss.

Not only can imperfections from massive weight loss bring patients a
dissatisfaction of appearance but it can affect functional abilities as well
such as difficulty exercising, impaired ambulation, chronic pain, and hygiene
difficulties. Dermatological issues such as uncontrolled intertrigo,
infections and skin necrosis can also develop.

Practice parameters for patients who are preparing to undergo surgery for
removal of excess skin and fat are screened and assessed preoperatively. This
includes screening for depression, diabetes mellitus, gastroesophageal reflux
disease (GERD), nutritional deficiencies if any, abdominal wall hernias, and
preoperative lab and diagnostic testing.

Excess skin that remains after significant weight loss is nearly impossible to
rectify with diet, weight loss or exercise. Non-surgical candidates are left
with very few alternatives for treatment. Alternative treatments such as
radiofrequency or ultrasound demonstrate minimal effect and result. Surgical
candidates should maintain a stable weight for 2 to 6 months for body
contouring. Those patients who have undergone bariatric surgery stable weight
is usually reached at 12 to 18 months.

Sachs et al12 performed an overview of panniculectomy and some of the
indications and clinical significance of performing the procedure.
Panniculectomy is not a cosmetic procedure and must meet medically necessary
criteria. The procedure is performed to remove the excess skin and fat
incurred from weight gain. This can cause large overhanging abdominal skin
known as a pannus which can sometimes cover the thighs, hips and knees. This
excess can cause difficulty with daily activities and cause skin infections
and rashes like intertrigo due to irritation and sweating. Typically, patients
with skin conditions receive medical treatment with topical antifungals,
corticosteroids, and antibiotics.

How far the pannus extends is graded 1 through 5. Grade 1 is the pannus
reaching the mons pubis and grade 5 is the pannus extending to or past the
knees. For a patient to qualify for a panniculectomy they usually must fail 3
months of medical treatment for intertrigo, and the pannus must hang below the
level of the pubis, and confirmed with photography. A panniculectomy is
performed to remove the excess skin and fat to relieve the associated symptoms
and restore normal function.

Persons who experience dramatic weight loss also can have excess lower
abdominal skin which hangs over the groin and pubic areas. This causes issues
with walking, discomfort and skin irritation as well. Patients who have lost
weight without surgery must maintain stable weight for at least 6 months prior
to undergoing a panniculectomy. For those bariatric surgery patients, weight
must remain stable for at least 18 months, including the most recent 6 months.

While there are many studies focused on clinical outcomes of abdominoplasty,
there are few looking at the advantage of abdominal lipectomy.32 Abdominal
lipectomy is performed to remove excess abdominal tissue where there is little
to no abdominal wall undermining, and there is no gathering of abdominal
muscle performed with exception to a ventral hernia. Semer et al32 performed a
prospective outcome study on patients who underwent an abdominal lipectomy
during a 12 month period from September 2004 to September 2005. Data was
obtained at the preoperative visit, during surgery, and at the 1 week, 1
month, and 6 month visits postoperatively.

There are both major and minor complications that can occur with abdominal
lipectomy. A major complication is possible rehospitalization or a subsequent
operation is needed, whereas minor complications result in ongoing outpatient
care. The authors administered the Short Form-36 Health Survey and the
Multidimensional Body-Self Relations Questionnaire to 72 patients enrolled in
the study, to assess perceived health, well-being and body image following
abdominal lipectomy. The results of the study were that at the end of the 6
month follow-up period, data collected from 59 of 60 patients showed they were
happy to have had the surgery. The authors found through the results of the
study that abdominal lipectomy is a safe and effective treatment for
correcting the symptoms from a lower abdominal pannus.

Available literature and the American Society of Plastic Surgeons supports
that not all plastic surgery procedures are simply cosmetic in nature and
certain procedures are medically reasonable and necessary where functionality
needs to be restored and any deformities need to be corrected.

The FDA2 provides guidance on the risks and complications of breast implants.
This LCD is providing limited coverage for the removal of breast implants,
whether placed for reconstructive or cosmetic purposed. The indications for
removal are based on the complications and/or adverse outcomes published by
the FDA.

The American Society of Plastic Surgeons9 has published clinical guidelines
for reduction mammoplasty to treat symptomatic breast hypertrophy as there is
no lasting non-surgical treatment proven effective. Schnur and colleagues33
reported in a study, based on questionnaire responses from women who had
undergone reduction mammoplasty that in properly selected individuals,
reduction mammoplasty is safe and effective for relieving and improving
symptoms related to macromastia. The medical literature supports an approach
based on the measurement of body surface area such as the Schuner scale.
Medical evidence and expert medical opinion support the use of the Schuner
scale to ensure that an adequate amount of breast tissue is removed in order
to provide maximum symptomatic relief. Additionally, experts in the specialty
agree that breasts are considered paired organs, and it is not possible to
definitely relate symptoms to one breast or the other. Therefore, bilateral
breast reduction mammoplasty may be considered appropriate if the amount of
breast tissue anticipated for removal from at least 1 breast meets the minimum
amount (weight) per the Schnur scale and all other criteria are met.

There are many pieces of literature, including guidelines and consensus
statements, which support nasal surgery as the treatment for nasal airway
obstructions. These obstructions can be caused by a deviated septum, collapsed
internal/external valves, congenital defects, or trauma. The patient should be
preoperatively evaluated to determine which anatomical structure of the nasal
airway us causing the obstruction and plan the appropriate surgical
intervention. Most conditions require failure of conservative treatment such
as steroids, decongestants, and dilators before undergoing surgery as the
final step. Literature supports the use of anterior rhinoscopy, endoscopy,
and/or Cottle maneuver as part of the diagnostic process.

Dermabrasion is used for treating various dermatological conditions such as
acne scars, wrinkles, and different forms of rosacea. While these are
considered cosmetic in nature, rhinophyma is causes functional impairment or
deformities. Rhinophyma can cause thickening of the nasal skin that can
develop into structural deformities that impede on the nasal airway openings
leading to respiratory problems. While there is no gold standard for treating
this condition, the goal is to remove the hypertrophic skin. The literature
supports that dermabrasion is a safe and successful procedure for rhinophyma
with positive outcomes. This LCD will provide limited coverage for the use of
dermabrasion as a treatment for rhinophyma.

When patients lose large amounts of weight and are left with loose excess skin
and fat, additional weight loss or exercise will not correct it. A
panniculectomy is medically necessary when excess skin and fat impedes the
patient's activities of daily living, ability to perform appropriate hygiene,
causes chronic pain, dermatologic issues and impairs the ability to walk or
exercise. The literature supports providing limited coverage for
panniculectomy in the treatment of excess skin and fat of the abdomen when the
above criteria are met.