Billing and Coding: Plastic Surgery

Cosmetic surgery is excluded from coverage, but reconstructive plastic surgery for therapeutic indications (e.g., severe burns, facial trauma repair) is covered. Reduction mammoplasty may be covered only when symptomatic macromastia is documented with severe symptoms and adverse impact on quality of life measured by an accepted breast-specific questionnaire, persistent symptoms after a reasonable trial of conservative therapy, and required documentation (height/weight, clinical evaluation, operative and pathology reports) is present; lacking documentation or unsupported ICD-10 coding may result in denial.

"Reconstructive plastic surgery is covered when performed for therapeutic purposes such as treatment of severe burns, facial repair following auto trauma, or similar reconstructive/therapeutic surgery."

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