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If an entity wishes to utilize any AHA materials, please contact the AHA at 31.Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in anyProduct or publication creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions and/or making any commercial use of UB-04Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association.To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816. Reproduced by CMS with permission.No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA.AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution orDerivative work without the written consent of the AHA. All rights reserved.Copyright В© 2013 - 2021, the American Hospital Association, Chicago, Illinois. The AMA does not directly or indirectly practice medicine or dispense medical services.The AMA assumes no liability for data contained or not contained herein.Current Dental Terminology В© 2020 American Dental Association. Applicable FARS/HHSARS apply.Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is notRecommending their use.

Dermabrasion performed for post-acne scarring is classified as cosmetic and is not covered for payment.Group 2: Abdominal Lipectomy/PanniculectomyAbdominal lipectomy/panniculectomy is surgical removal of excessive fat and skin from the abdomen. 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, e.g., craniofacial anomalies associated with Treacher Collins syndrome may be considered on an individual basis.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:Coverage will be provided when correcting defects resulting from traumatic injury, surgery or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.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.

Treating psychological symptomatology or psychosocial complaints Repairing abdominal wall laxity or diastasis recti 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 3 to 6 months.Palmetto GBA 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): 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 3 to 6 months. There is no adequate evidence that pannus contributes to hernia formation. Preoperative photographs may be required to support justification and should be supplied upon request.Palmetto GBA considers panniculectomy medically necessary when the 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 over 3 months while receiving appropriate medical therapy, or remains refractory to appropriate medical therapy over a period of 3 months.Palmetto GBA considers panniculectomy experimental and investigational for minimizing the risk of hernia formation or recurrence.

To reduce the size of the breasts and help ameliorate symptoms caused by hypertrophy Unilateral hypertrophy may result in symptoms following contralateral mastectomy. Breast hypertrophy may adversely affect other body systems (e.g., musculoskeletal, respiratory, integumentary). Painful capsular contracture with disfigurementMacromastia (breast hypertrophy) is disproportionate volume and weight of breast tissue relative to the general body habitus. Interference with diagnosis of breast cancer

Cosmetic signs and/or symptoms would include ptosis, poorly fitting clothing and beneficiary perception of unacceptable appearance. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, В§140.2.Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit. To improve symmetry following cancer surgery on one breastNOTE: For coverage indications for contralateral reconstruction of an unaffected breast following a medically necessary mastectomy, refer to the CMS Internet-Only Manual, Pub. There are signs and/or symptoms resulting from the enlarged breasts (macromastia) that have not responded adequately to non-surgical interventions

2021.11

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