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Aetna Aetna
Clinical Policy Bulletin:
Cosmetic Surgery
Number: 0031


Policy

Introduction

Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, but generally provide coverage when the surgery is needed to improve the functioning of a body part or otherwise medically necessary even if the surgery also improves or changes the appearance of a portion of the body.  Additionally, many Aetna plans specify that certain procedures are not considered to be cosmetic surgery (e.g., surgery to correct the result of injury, post-mastectomy breast reconstruction, surgery needed to treat certain congenital defects such as cleft lip or cleft palate).  Please check benefit plan descriptions for details.

This policy statement supplements plan coverage language by identifying procedures that Aetna considers medically necessary despite cosmetic aspects, and other cosmetic procedures that Aetna considers not medically necessary.  Please note that, while this policy statement addresses many common procedures, it does not address all procedures that might be considered to be cosmetic surgery excluded from coverage.  Aetna reserves the right to deny coverage for other procedures that are cosmetic and not medically necessary.

Clinical Statements

The following procedures are considered cosmetic in nature:

  • Aesthetic operations on umbilicus
  • Breast augmentation (breast implants and pectoral implants) (for medical necessity criteria for breast reconstruction, see CPB 0185 - Breast Reconstructive Surgery) (see also CPB 0142 - Breast Implant Removal)
  • Breast lift (mastopexy)
  • Buttock lift or augmentation
  • Cheek implant (malar implant/augmentation)
  • Chin implant (genioplasty, mentoplasty)
  • Correction of inverted nipple
  • Ear or body piercing
  • Electrolysis or laser hair removal
  • Excision of excessive skin of thigh (thigh lift, thighplasty), leg, hip, buttock, arm (arm lift, brachioplasty), forearm or hand, submental fat pad, or other areas (see CPB 0211 - Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair)
  • Lacrimal gland resuspension for lacrimal gland prolapse
  • Mesotherapy (injection of various substances into the tissue beneath the skin to sculpt body contours by lysing subcutaneous fat)
  • Neck Tucks
  • Removal of frown lines
  • Removal of spider angiomata
  • Removal of supernumerary nipples (polymastia)
  • Salabrasion
  • Surgery to correct moon face
  • Surgery to correct tuberous breast deformity
  • Surgical depigmentation (e.g., laser treatment) of nevus of Ito or Ota
  • Treatment with small gel-particle hyaluronic acid (e.g., Restylane) and large gel-particle hyaluronic acid (e.g., Perlane) to improve the skin's contour and/or reduce depressions due to acne, injury, scars, or wrinkles
  • Vaginal rejuvenation procedures (clitoral reduction, designer vaginoplasty, hymenoplasty, re-virgination, G-spot amplification, pubic liposuction or lift, reduction of labia minora, labia majora surgery/reshaping, and vaginal tightening, not an all-inclusive list)

The following procedures are considered medically necessary when criteria are met.  The requesting physicians may be required to submit documentation, including photographs, letters documenting medical necessity, chart records, etc.

  • Blepharoplasty: Considered medically necessary when criteria in CPB 0084 - Ptosis Surgery, are met.
  • Breast reduction: Considered medically necessary when criteria in CPB 0017 - Breast Reduction Surgery and Gynecomastia Surgery, are met.
  • Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne Surgery are met.
  • Collagen implant (e.g., Zyderm): Considered cosmetic except as a treatment for urinary incontinence when medical necessity criteria in CPB 0223 - Urinary Incontinence Treatments are met.
  • Dermabrasion: Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peel, and Acne Surgery are met.
  • Dermal injections of FDA-approved fillers (e.g., poly-L-lactic acid dermal injection (Sculptra) or calcium hydroxylapatite dermal injection (Radiesse)) for HIV lipoatrophy: Considered medically necessary for treating facial lipodystrophy syndrome due to antiretroviral therapy in HIV-infected persons; considered cosmetic for all other indications. Retreatments with FDA-approved fillers are considered medically necessary for facial lipodystrophy syndrome due to antiretroviral therapy in HIV-infected persons.
  • Earlobe repair: Repair (e.g., tear) of a traumatic injury is considered medically necessary.  Earlobe repair to close a stretched pierce hole, in the absence of a traumatic injury, is considered cosmetic.
  • Excision or shaving of rhinophyma for the treatment of bleeding or infection refractory to medical therapy (i.e. the need for repeated cautery of bleeding telangiectasias or frequent courses of antibiotics for pustular eruptions).  Excision or shaving of rhinophyma is considered cosmetic when the afore-mentioned criteria are not met.
  • Keloids: Repair of keloids is considered medically necessary if they cause pain or a functional limitation.  Note: For repair of keloids that do not cause pain or functional impairment, exceptions to cosmetic surgery exclusion may apply.  Please check benefit plan descriptions.  See also CPB 0551 - Radiation Treatment for Selected Nononcologic Indications.
  • Lipectomy or liposuction and autologous fat grafting are considered medically necessary for breast reconstruction according to the medical necessity criteria in CPB 0185 - Breast Reconstruction Surgery.
  • Lipomas: Excision is considered medically necessary if lipomas are tender and inhibit the member's ability to perform daily activities due to the lipomas' location on body parts that are subject to regular touch or pressure.
  • Otoplasty/Pinnaplasty: Considered medically necessary when performed to improve hearing by directing sound in the ear canal, whether the ears are absent or deformed from trauma, surgery, disease, or congenital defect.  Otoplasty to correct large or protruding ears (bat ears) is considered cosmetic when the surgery will not improve hearing.
  • Panniculectomy: Considered medically necessary when criteria are met, as set forth in CPB 0211 - Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair.
  • Phalloplasty for transgender (female to male) surgery: Consideded medically necessary when criteria are met, as set forth in CPB 0615 - Gender reassignment Surgery.
  • Pulsed-dye laser treatment and excision of port wine stains and other hemangiomas: Considered medically necessary when lesions are located on the face and neck.  Also, removal of symptomatic scrotal hemangiomas and symptomatic cavernous hemangiomas is considered medically necessary.  See also CPB 0559 - Pulsed Dye Laser Treatment.
  • Rhinoplasty: Considered medically necessary for indications set forth in CPB 0005 - Septoplasty and Rhinoplasty.
  • Rhytidectomy (including meloplasty, face lift): Considered medically necessary when there is functional impairment that cannot be corrected without surgery.
  • Scar revision: Repair of scars that result from surgery is considered medically necessary if they cause symptoms or functional impairment.  Note: Exceptions to cosmetic surgery exclusion may apply to repair of scars that do not cause pain or functional impairment.  Please check benefit plan descriptions.
  • Septoplasty: Considered medically necessary when criteria are met, as set forth in CPB 0005 - Septoplasty and Rhinoplasty.
  • Skin tag removal: Considered medically necessary when located in an area of friction with documentation of repeated irritation and bleeding.
  • Tattoo: Considered medically necessary in conjunction with reconstructive breast surgery post-mastectomy, and for marking for radiation therapy.  See CPB 0185 - Breast Reconstructive Surgery.
  • Ventral hernia repair: Considered medically necessary when criteria are met, as set forth in CPB 0211 - Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair.

Implantation and attachment of prostheses

Note: Most Aetna plans cover prosthetic devices that temporarily or permanently replace all or part of an external body part that is lost or impaired as a result of disease, injury or congenital defect.  The surgical implantation or attachment of covered prosthetics is covered, regardless of whether the covered prosthetic is functional (i.e., regardless of whether the prosthetic improves or restores a bodily function).  The following surgical implantations are covered when medical necessity criteria for the prosthetic device are met, even though the prosthetic device does not correct a functional deficit.

The following prostheses are considered medically necessary when criteria are met:

See also the following CPBs that address other procedures that may be considered cosmetic:



Background

Mest and Humble (2009) evaluated the long-term safety, duration of effect, and satisfaction with serial injections of poly-l-lactic acid (PLLA) for HIV-associated facial lipoatrophy.  In this single-site, open-label, re-treatment study, 65 HIV-positive patients were treated with injectable PLLA every 5 weeks (until optimal re-correction).  Presenting degree of lipoatrophy based on the James scale (1 = mild, 4 = severe) was reviewed.  Skin thickness was measured at fixed points with calipers.  Patients completed a post-retreatment satisfaction questionnaire.  Nearly 10 % of patients had persistent correction greater than 36 months, based on patient report.  Approximately 50 % required 3 or fewer re-treatments to maintain satisfactory correction (determined by patient and physician).  Milder facial lipoatrophy (james scale score 1 to 2) on initial presentation required fewer re-treatments and had more sustained correction.  Time to first re-treatment varied according to James scale score: 1 (21.4 months) and 4 (13.0 months).  The majority of patients required or asked for 4 re-treatments or less over a 24-month period.  The mean patient satisfaction score was 4.9 (1 = dissatisfied, 5 = very satisfied) at study end.  No serious adverse events were reported.  The authors concluded that injectable PLLA is a safe and effective long-term treatment option for HIV-associated lipoatrophy.

The cosmetic surgery exclusion precludes payment for any surgical procedure directed at improving appearance.  The condition giving rise to the patient's pre-operative appearance is generally not a consideration.  The only exception to the exclusion is surgery for the prompt repair of an accidental injury or for the improvement of a malformed body member which coincidentally serves some cosmetic purpose.  Since surgery to correct a condition of "moon face" which developed as a side effect of cortisone therapy does not meet the exception to the exclusion, it is not covered under Medicare (§1862(a)(10) of the Act).

An UpToDate review on “Overview of breast disorders in children and adolescents” (Banikarim and De Silva, 2012) states that “Tuberous breast is a variant of breast development in which the base of the breast is limited and the nipple and areola are overdeveloped.  The etiology is unknown.  If the breast examination is otherwise normal, the patient may be referred for cosmetic surgery.  The available surgical options vary depending on the location of the hypoplastic breast tissue …. Teenagers may seek breast augmentation for reconstructive purposes related to congenital defects (e.g., amastia, severe breast asymmetry, tuberous breast) or for purely aesthetic reasons”. 

Fodd and Drug Administration-approved for the correction of moderate-to-severe facial wrinkles and folds, small gel-particle hyaluronic acid (SGP-HA, Restylane, Medicis Aesthetics, Inc., Scottsdale, AZ) and large gel-particle hyaluronic acid (LGP-HA, Perlane, Medicis Aesthetics, Inc., Scottsdale, AZ) were studied to evaluate their safety for the correction of oral commissures, marionette lines, upper perioral rhytides and naso-labial folds (NLFs).  Brandt et al (2011) examined the safety of SGP-HA and LGP-HA in treating facial wrinkles and folds around the mouth; the secondary objective was to evaluate the effectiveness of these products.  This open-label, 4-week study at 2 U.S. centers evaluated SGP-HA and LGP-HA in patients who intended to undergo intradermal injection for correction of perioral wrinkles and folds.  At screening, a 5-grade Wrinkle Severity Rating Scale (WSRS) was used to evaluate the baseline appearance of bilateral NLFs, and a 6-grade Wrinkle Severity (WS) scale was used to evaluate the appearance of bilateral oral commissures, marionette lines and upper perioral rhytides.  To qualify, each patient must have had moderate-to-severe wrinkles at 1 pair of marionette lines and upper perioral rhytides.  Each wrinkle was treated to optimal correction with either SGP-HA or LGP-HA at the discretion of the treating investigator.  All reported local and systemic adverse events (AEs) were recorded.  At 2 weeks after treatment or touch-up, the treating investigator and the patient assessed appearance using the Global Aesthetic Improvement Scale (GAIS).  A total of 20 patients with a mean age of 59.6 years (range of 49 to 65) were treated with an average of 5.58 +/- 1.15 ml of HA for the entire perioral area.  Treatment areas included NLFs, marionette lines, oral commissures and perioral rhytides; 18 of 20 patients received both SGP-HA and LGP-HA.  Product was injected into the mid or deep dermis using primarily linear threading and multiple punctate pools.  Patients experienced a total of 66 treatment-emergent AEs (TEAEs); each patient experienced at least 1 TEAE.  The reported events in decreasing order of occurrence were bruising, tenderness, swelling, redness, headache and discomfort.  Bruising was more common in the NLFs and marionette lines than in the oral commissures and perioral rhytides.  Tenderness occurred more often in the perioral rhytides than in the other areas.  The maximum intensity of all TEAEs was considered mild.  Most TEAEs resolved within 7 days, with an average duration of 4 days.  No serious TEAEs occurred during the study; 100 % of GAIS evaluations by both investigators and patients indicated improvement, regardless of filler used or area treated.  The authors concluded that both SGP-HA and LGP-HA were found to be safe and effective for the correction of perioral wrinkles and folds, with few differences among treatment areas.   Both investigator and patient GAIS evaluations indicated aesthetic improvement after SGP-HA and LGP-HA treatment in the perioral area.

Cohen et al (2013) systematically reviewed published evidence for aesthetic use of SGP-HA and LGP-HA.  Clinical data on anatomic area, level of evidence, patient population, trial design, endpoints, efficacy, and safety were extracted from PubMed.  A total of 53 primary clinical reports were analyzed.  The highest-quality efficacy evidence was for the NLFs, with 10 randomized, blind, split-face, comparative trials.  Several randomized, blind trials supported treatment of the glabella, lips, and hands.  Lower-level evidence (from studies with non-randomized, open-label, or retrospective designs) was recorded for the naso-jugal folds (tear troughs), upper eyelids, nose, infra-orbital hollows, oral commissures, marionette lines, perioral rhytides, temples, and cheeks.  Common AEs across anatomic areas were pain, bruising, swelling, and redness.  Serious AEs were uncommon (8 events in 8 patients of 4,605 total patients) and were considered to be unrelated (7 events) or probably unrelated (1 event) to treatment.  The authors concluded that the safety and effectiveness of SGP-HA and LGP-HA are well-established for NLFs; evidence for the glabella, lips, and hands is more limited.  Preliminary reports in other anatomic regions suggested effectiveness without major complications.

While products containing a hyaluronic acid gel (e.g., Perlane and Restylane) are available to improve the contours of the skin, the presence of depressions and/or wrinkles is not a functional impairment.  Thus, the use of SGP- HA and LGP-HA for improvement of the skin's contour and/or reduce depressions due to acne, injury, scars, or wrinkles is cosmetic.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
11200
11300 - 11313
11400 -11446
11920 - 11922
11950 - 11954
12011
12051
15220 - 15221
15780 - 15782
15788 - 15793
15820 - 15823
15830
15840 - 15845
15877
17106 - 17108
17360
19318 - 19350, 19357 - 19396
20926
21740 - 21743
30120
30420, 30435, 30450, 30460, 30462
30520
37785
51715
54660
67901 - 67909
CPT codes not covered for indications listed in the CPB:
+ 11201
15775 - 15776
15783
15786 - 15787
15819
15824 - 15829
15832 - 15839
+ 15847
15876
15878 - 15879
17110
17111
17380
19120
19300
19316
19355
21120 - 21123
21125 - 21127
21137 - 21139
21270
21280
21282
26590
30400 - 30410
30430
31830
49250
49560 - 49561
49565 - 49566
+ 49568
56620
56800
56805
56810
57291 - 57292
57335
69090
69300
HCPCS codes covered if selection criteria are met:
C9800 Dermal injection procedure(s) for facial lipodystrohy syndrome (LDS) and provision of Radiesse or Sculptra dermal filler, including all items and supplies
D5914 Auricular prosthesis
D5916 Ocular prosthesis
D7995 Synthetic graft - mandible or facial bones, by report
G0429 Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy)
L8000 - L8039 Breast prostheses
L8040 - L8049 Nasal, midfacial, orbital, upper facial, hemi-facial, auricular, partial facial, nasal septal, and maxillofacial prostheses
L8600 Implantable breast prosthesis, silicone or equal
L8603 Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies
L8610 Ocular implant
Q2026 Injection, Radiesse, 0.1 ml
Q2028 Injection, sculptra, 0.5 mg
Q3031 Collagen skin test
S2075 Laparoscopy, surgical; repair incisional or ventral hernia
S2077 Laparoscopy, surgical; implantation of mesh or other prosthesis for incisional or ventral hernia repair (List separately in addition to code for incisional or ventral hernia repair)
V2623 - V2629 Prosthetic eye
HCPCS codes not covered for indications listed in the CPB:
D5919 Facial prosthesis
D5925 Facial augmentation implant prosthesis
S8948 Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes
ICD-9 codes covered if selection criteria are met:
042 Human immunodeficiency virus [HIV] disease [covered for facial lipodystrophy syndrome due to antiretroviral therapy in HIV-infected persons]
140.0 – 209.36 Malignant neoplasms [covered for tattooing for radiation therapy only]
198.81 Secondary malignant neoplasm of breast
214.0 - 214.8 Lipoma
228.01 Hemangioma of skin and subcutaneous tissue
233.0 Carcinoma in situ of breast
599.84 Other specified disorders of urethra
610.1 Diffuse cystic mastopathy
625.6 Stress incontinence, female
695.3 Rosacea [rhinophyma]
701.4 Keloid scar
701.9 Other hypertrophic and atrophic conditions of skin
702.0 Actinic keratosis
705.21 Primary focal hyperhidrosis
706.0 - 706.1 Acne
744.00 - 744.09 Anomalies of ear causing hearing impairment
749.10 - 749.14 Cleft lip
757.32 Vascular hamartomas
788.30 - 788.39 Urinary incontinence
V08 Asymptomatic human immunodeficiency virus [HIV] infection status [covered for facial lipodystrophy syndrome due to antiretroviral therapy in HIV-infected persons]
V10.3 Personal history of malignant neoplasm of breast
V45.71 Acquired absence of breast
ICD-9 codes not covered for indications listed in the CPB:
216.3 Benign neoplasm of skin [nevus of Ota]
216.6 Benign neoplasm of skin [nevus of Ito]
302.0 - 302.9 Sexual and gender identity disorders
611.79 Other signs and symptoms of breast [inverted nipple]
624.3 Hypertrophy of labia
676.00 - 676.04 Other disorders of the breast associated with childbirth and disorders of lactation, retracted nipple [inverted nipple]
676.30 - 676.34 Other disorders of the breast associated with childbirth and disorders of lactation, other and unspecified disorder of breast [inverted nipple]
701.8 Other specified hypertrophic and atrophic condition of skin [wrinkling of skin]
704.1 Hirsutism
728.84 Diastasis of muscle
754.82 Pectus carinatum
757.6 Specified congenital anomalies of breast [inverted nipple] [supernumerary nipple (polymastia)]
Other ICD-9 codes related to the CPB:
272.6 Lipodystrophy
278.00 - 278.02 Overweight and obesity
278.1 Localized adiposity
374.30 - 374.34 Ptosis of eyelid
380.32 Acquired deformities of auricle or pinna
448.1 Nevus, non-neoplastic
524.04 Mandibular hypoplasia
551.20 - 551.29, 552.20 - 552.29, 553.20 - 553.29 Ventral hernia
611.1 Hypertrophy of breast
704.00 - 704.09 Alopecia
709.2 Scar conditions and fibrosis of skin
743.00 Clinical anophthalmos
743.61 Congenital ptosis
744.21 - 744.3 Other and unspecified anomalies of ear
752.8 Other specified anomalies of genital organs
756.0 Anomalies of skull and face bones
756.79 Other congenital anomalies of abdominal wall
905.0 - 909.9 Late effects of injuries, poisonings, toxic effects, and other external causes
959.09 Injury of face and neck
E931.7 Antiviral drugs causing adverse effects in therapeutic use
V15.5 Personal history of injury
V45.77 Acquired absence of genital organs
V45.78 Acquired absence of eye
V49.60 - V49.77 Upper and lower limb amputation status
V50.1 Other plastic surgery for unacceptable cosmetic appearance


The above policy is based on the following references:
  1. Hoeyberghs JL. Fortnightly review: Cosmetic surgery. BMJ. 1999;318(7182):512-516.
  2. Kuzon WM Jr. Plastic surgery. J Am Coll Surg. 1999;188(2):171-177.
  3. Grover R, Sanders R. Plastic surgery. BMJ. 1998;317(7155):397-400.
  4. McClean K, Hanke CW. The medical necessity for treatment of port-wine stains. Dermatol Surg. 1997;23(8):663-667.
  5. Hallock GG. Cosmetic trauma surgery. Plast Reconstr Surg. 1995;95(2):380-381.
  6. Amaral MJ. Plastic surgery or esthetic surgery? Acta Med Port. 1998;11(2):97-99.
  7. Mogelvang C. Cosmetic versus reconstructive surgery. Plast Reconstr Surg. 1997;99(7):2115-2116.
  8. Kucan JO, Lee RC. Plastic surgery. JAMA. 1996;275(23):1844-1845.
  9. Zook EG. Plastic surgery. JAMA. 1994;271(21):1703-1704.
  10. BlueCross BlueShield of Pennsylvania, Xact Medicare Services. Cosmetic surgery vs. reconstructive surgery. Medicare Medical Policy Bulletin No. S-28F. Camp Hill, PA: Xact Medicare Services; November 24, 1997. Available at: http://www.hgsa.com/professionals/policy/s28.html. Accessed November 16, 2001.
  11. Cyr PR. Folliculitis. eMedicine Dermatology Topic 159. Omaha, NE: eMedicine.com; November 5, 2001. Available at: http://www.emedicine.com/derm/topic159.htm. Accessed June 23, 2003.
  12. Kwon SD, Kye YC. Treatment of scars with a pulsed Er:YAG laser. J Cutan Laser Ther. 2000;2(1):27-31.
  13. Tanzi EL, Alster TS. Treatment of atrophic facial acne scars with a dual-mode Er:YAG laser. Dermatol Surg. 2002;28(7):551-555.
  14. Alster T. Laser scar revision: Comparison study of 585-nm pulsed dye laser with and without intralesional corticosteroids. Dermatol Surg. 2003;29(1):25-29.
  15. Papadavid E, Katsambas A. Lasers for facial rejuvenation: A review. Int J Dermatol. 2003;42(6):480-487.
  16. Cooter R, Babidge W. Ultrasound-assisted lipoplasty. North Adelaide, South Australia: Australian Safety and Efficacy Register of New Interventional Procedures - Surgical (ASERNIP-S); 1999.
  17. Medical Services Advisory Committee (MSAC). Total ear reconstruction. Canberra, Australia: Medical Services Advisory Committee; 2000.
  18. State of Minnesota, Health Technology Advisory Committee (HTAC). Tumescent liposuction. St. Paul, MN: HTAC; 2002.
  19. Fischbacher C. Cosmetic breast augmentation. Bazian Ltd., eds. London, UK: Wessex Institute for Health Research and Development, University of Southampton; 2003.
  20. Ball CM. Laser treatment of unwanted hair. Bazian Ltd., eds. London, UK: Wessex Institute for Health Research and Development, University of Southampton; 2003.
  21. Patterson J. Outcomes of abdominoplasty. Bazian Ltd., eds. London, UK: Wessex Institute for Health Research and Development, University of Southampton; 2003.
  22. Lafaurie M, Dolivo M, Porcher R, et al. Treatment of facial lipoatrophy with intradermal injections of polylactic acid in HIV-infected patients. J Acquir Immune Defic Syndr. 2005;38(4):393-398.
  23. Beljaards RC, de Roos KP, Bruins FG. NewFill for skin augmentation: A new filler or failure? Dermatol Surg. 2005;31(7 Pt 1):772-776; discussion 776.
  24. American College of Obstetricians and Gynecologists (ACOG). Vaginal 'rejuvenation' and cosmetic vaginal procedures. ACOG Committee Opinion No. 378. Washington, DC: ACOG; September 2007.
  25. Vedamurthy M. Mesotherapy. Indian J Dermatol Venereol Leprol. 2007;73(1):60-62.
  26. Rastogi R. Diffuse cavernous hemangioma of the penis, scrotum, perineum, and rectum -- a rare tumor. Saudi J Kidney Dis Transpl. 2008;19(4):614-618.
  27. Atiyeh BS, Ibrahim AE, Dibo SA. Cosmetic mesotherapy: Between scientific evidence, science fiction, and lucrative business. Aesthetic Plast Surg. 2008;32(6):842-849.
  28. Park SH, Kim DW, Lee MA, et al. Effectiveness of mesotherapy on body contouring. Plast Reconstr Surg. 2008;121(4):179e-185e.
  29. Ergün O, Ceylan BG, Armagan A, et al. A giant scrotal cavernous hemangioma extending to the penis and perineum: A case report. Kaohsiung J Med Sci. 2009;25(10):559-561.
  30. Centers for Medicare & Medicaid Services (CMS). Decision memo for dermal injections for the treatment of facial lipodystrophy syndrome (FLS) (CAG-00412N). Medicare Coverage Database. Baltimore, MD: CMS; March 23, 2010.
  31. Mest DR, Humble GM. Retreatment with injectable poly-l-lactic acid for HIV-associated facial lipoatrophy: 24-month extension of the Blue Pacific study. Dermatol Surg. 2009;35 Suppl 1:350-359.
  32. Centers for Medicare & Medicaid Services. National coverage determination (NCD) for plastic surgery to correct "Moon Face" (140.4). CMS; Baltimore, MD. May 1, 1989. Available at: http://cms.hhs.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=14&ncdver=1&bc=AgAAQAAAAAAA&. Accessed October 23, 2012.
  33. Banikarim C, De Silva NK. Overview of breast disorders in children and adolescents. Last reviewed November 2012. UpToDate Inc. Waltham, MA.
  34. Brandt F, Bassichis B, Bassichis M, et al. Safety and effectiveness of small and large gel-particle hyaluronic acid in the correction of perioral wrinkles. J Drugs Dermatol. 2011;10(9):982-987.
  35. Cohen JL, Dayan SH, Brandt FS, et al. Systematic review of clinical trials of small- and large-gel-particle hyaluronic acid injectable fillers for aesthetic soft tissue augmentation. Dermatol Surg. 2013;39(2):205-231.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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