PROVIDER POLICIES & PROCEDURES

Page created by Wesley Woods

Health & Fitness

English

Like
Share
Embed
Fullscreen
Slides
Download HTML
Download PDF
Abuse

←

→

Page content transcription

If your browser does not render page correctly, please read the page content below

PROVIDER POLICIES &
PROCEDURES
________________________________________________________________________

RECONSTRUCTIVE AND COSMETIC SURGERY

The purpose of this document is to provide guidance to providers enrolled in the Connecticut Medical
Assistance program (CMAP Providers) on the requirements for the prior authorization of reconstructive
and cosmetic surgical procedures. This includes the applicable coverage guidelines and limitations for
HUSKY Health Program members as well as the procedures for requesting authorization for these
services.

Reconstructive surgery is a surgical procedure performed on a patient to improve, or restore, an
individual’s optimum physical functioning. The need for reconstructive surgery in a given individual may
be the result of a congenital deformity, an injury, an infection, a disease, or, in some instances, is related
to a previous therapeutic process. Although a reconstructive surgical procedure may have inherent
cosmetic benefits, it is considered to be primarily undertaken for reconstructive purposes.

Cosmetic surgery, on the other hand, is generally performed on patients to reshape normal structures of
the body for purposes of improving appearance and/or self-esteem. Cosmetic surgery, which may also
be referred to as “body contouring,” is primarily intended to preserve or improve physical appearance, but
has no significant effect on body function.

The HUSKY Health Program covers surgical procedures that are reconstructive in nature; cosmetic
surgery is typically not covered.

POLICY
Coverage guidelines for reconstructive and cosmetic procedures are made in accordance with the
Department of Social Services (DSS) Definition of Medical Necessity. The following criteria are
guidelines only. Coverage determinations are based on an individual assessment of the member and his
or her clinical needs.

NOTE: EPSDT Special Provision
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal Medicaid requirement that
requires the Connecticut Medical Assistance Program (CMAP) to cover services, products, or procedures
for Medicaid enrollees under 21 years of age where the service or good is medically necessary health
care to correct or ameliorate a defect, physical or mental illness, or a condition identified through a
screening examination. The applicable definition of medical necessity is set forth in Conn. Gen. Stat.
Section 17b-259b (2011) [ref. CMAP Provider Bulletin PB 2011-36].

General Guidelines: Reconstructive Surgery
Reconstructive surgery, as defined above, may be considered clinically appropriate when the given
procedure:
1. Improves or restores physical function;
Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment. Payment
is based on the member having active coverage, benefits and policies in effect at the time of service.

To determine if a service or procedure requires prior authorization, CMAP Providers may refer to the Benefit and Authorization Grids summaries
on www.huskyhealth.com by clicking here. For a definitive list of benefits and service limitations, CMAP Providers may access the CMAP
provider fee schedules and regulations at www.ctdssmap.com.

2. Corrects significant deformity resulting from disease, trauma, or previous therapeutic process
or procedure;
OR
3. Corrects congenital or developmental anomalies that have resulted in significant functional
impairment or disfigurement. Examples of congenital abnormalities are birthmarks, cleft lip
and palate, and hand deformities. Scarring due to burns and lacerations is considered
acquired.

General Guidelines: Cosmetic Surgery
Cosmetic surgery, as defined above, is typically not covered. Psychiatric and/or emotional distress is not
considered a medically necessary indication for coverage of cosmetic procedures.

NOTE: The following surgical procedures are always considered to be cosmetic and therefore are not
covered except in those instances when medical necessity is documented for a procedure generally
deemed cosmetic, but where such surgery, e.g., breast implant following surgery for breast cancer, etc.,
is considered reconstructive and general guidelines for reconstructive surgery are applicable as well as
specific guidelines for the given procedure.

1. Breast augmentation
2. Breast lift (mastopexy)
3. Buttock lift or augmentation
4. Cheek implant (malar implantation/augmentation)
5. Chin implant (genioplasty/mentoplasty)
6. Diastasis recti abdominis repair
7. Excision of excessive skin and subcutaneous tissue (including lipectomy) of abdomen, thigh
(thigh lift, thighplasty), leg, hip, buttock, arm (arm lift, brachioplasty), forearm, submental fat pad,
or other areas when medical necessity for coverage as a reconstructive surgical procedure is not
established.

Specific Guidelines: Panniculectomy
Panniculectomy is the removal of excessive skin, subcutaneous tissue, and fat of the abdominal wall.

Abdominoplasty, lipectomy, and lipoabdominoplasty are considered cosmetic procedures and typically not a
covered benefit. These procedures are to remove excess skin and fat from the middle and lower abdomen
and to tighten the muscles of the abdominal wall. They do not result in functional improvements.

Panniculectomy may be considered clinically appropriate when:
1. Panniculus hangs below the level of the pubis;
AND
There is suitable documentation in submitted contemporaneous medical records that the
panniculus is the cause of:
(a) Inability to maintain hygiene of lower abdomen and genital area;
OR
(b) Chronic intertrigo (irritant dermatitis occurring on opposed surfaces of the skin, skin
irritation, or chafing) that consistently recurs over period of three months while receiving

Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment. Payment
is based on the member having active coverage, benefits and policies in effect at the time of service.

appropriate medical therapy , (e.g., oral or topical prescription medication), or remains
refractory to appropriate medical therapy over a period of three months;

OR
(c) Recurrent or persistent skin infection under panniculus resistant to appropriate treatment
during a sufficient treatment period.
OR
2. Removal during ventral hernia repair.

NOTE: The hernia repair must be prior authorized separately.

Additional Information Required for Review of Panniculectomy:
1. Contemporaneous notes documenting medical conditions and complications, e.g., intertrigo
and/or infections, etc., with details of treatments, including duration and responses; and
2. Preoperative photograph(s), frontal and lateral views at a minimum; and additional photographs
as may be appropriate to document skin rashes, infection, etc., presented as indications for the
surgery.

Specific Guidelines: Ventral Hernia/Incisional Hernia Repair
A ventral hernia is defined as a hernia occurring in the abdominal wall at a site other than the groin.
Incisional hernias are those hernias occurring in a previous surgical incision.

Repair of ventral hernias is recommended, as they do not resolve spontaneously and may enlarge. It is
important to distinguish diastasis recti (a wide separation of rectus muscle) from a ventral hernia
(abdominal contents which project through the abdominal wall fascia). Diastasis recti is a normal
anatomic variation, and repair is considered cosmetic.

Abdominoplasty, lipectomy, or lipoabdominoplasty are considered cosmetic and typically not a covered
benefit. These procedures are to remove excess skin and fat from the middle and lower abdomen and to
tighten the muscles of the abdominal wall. They do not result in functional improvements.

Ventral Hernia or Incisional Hernia Repair may be considered clinically appropriate when:
1. Hernia is identified on physical examination;
OR
2. Hernia is identified through means of CT, MRI, or US.

Additional Information Required for Review of Ventral Hernia or Incisional Hernia Repair:
Contemporaneous documentation to distinguish a ventral hernia repair from a purely cosmetic
abdominoplasty is required. Documentation must include (a) size of hernia; (b) whether hernia is
reducible; (c) the extent of fascial defect.

Specific Guidelines: Breast Implant Removal
Breast implant removal may be considered clinically appropriate in circumstances where there is:
1. Implant extrusion through skin;
OR
2. Recurrent infections;
OR
3. Remnant breast cancer or cancer in contralateral breast;
Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment. Payment
is based on the member having active coverage, benefits and policies in effect at the time of service.

OR
4. Rupture of saline implant;

OR
5. Rupture of silicone gel-filled implant;
OR
6. Baker Class III contracture and localized pain;
OR
7. Baker Class IV contracture;
OR
8. Contracture that interferes with mammography studies in accordance with guidelines and
recommendations.

Baker Classification:
Class I Augmented breast feels soft as normal breast
Class II Augmented breast less soft and implant can be palpated, but is not visible.
Class III Augmented breast is firm, implant is palpable and implant is visible.
Class IV Augmented breast is hard, painful, cold, tender, and distorted.

NOTE: While removal of breast implants originally inserted for cosmetic reasons may be considered
clinically appropriate (see above) the reinsertion of new inserts is typically considered cosmetic. If initial
inserts were following a medically necessary mastectomy, re-insertion of implants is considered
reconstructive.

Additional Information Required for Review of Breast Implant Removal:
1. Copies of office notes documenting clinical reason for initial implant(s); and
2. Copies of office notes that document history and findings on physical exam.

Specific Guidelines: Reduction Mammoplasty
Reduction mammoplasty is surgery to remove substantial breast tissue, including skin and glandular
tissue, to reduce the size of the breast. Breast reduction surgery may be considered clinically
appropriate in instances where breast hypertrophy is a cause of pain, paresthesias, or skin-related
complications. Reduction mammoplasty for asymptomatic individuals is typically considered cosmetic.

Reduction mammoplasty for females ages 18 and older may be considered clinically appropriate when it
is being performed to remove breast tissue in the following circumstances:
1. Congenital absence or loss of significant breast tissue of the contralateral breast subsequent to
trauma or medically necessary mastectomy;
OR
2. Performed as part of reconstructive surgery that meets the requirements in section General
Guidelines: Reconstructive Surgery;
OR
3. Gigantomastia of pregnancy, accompanied by one of the following: massive infection; significant
infection; significant hemorrhage; tissue necrosis with slough; or ulceration of breast tissue;
OR
4. Macromastia (Gigantomastia) where:
a. At least 2 of the following 5 signs, symptoms, or conditions have been present for at least
1 year:
Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment. Payment
is based on the member having active coverage, benefits and policies in effect at the time of service.

1) Pain symptoms involving breast or back/neck/shoulder resulting in a functional
deficit (interference with daily activities or work) which has been documented by a

physician and which continue despite a minimum of three months of documented
therapeutic measures such as: analgesics, physical therapy, exercises, posturing
maneuvers and supportive devices;
2) Permanent shoulder grooving from undergarment straps;
3) Paresthesias of hands/arms;
4) Chronic intertrigo, eczema, dermatitis, and/or ulceration in the infra-mammary fold
unresponsive to dermatological treatments, (e.g., antibiotics or antifungal therapy,
etc.) and conservative measures (e.g., good skin hygiene, adequate nutrition) for a
period of 6 months or longer; and
5) Recurrent or persistent skin infection under breast.
AND
b. The surgeon’s estimate of breast tissue, not fatty tissue, to be removed from each breast,
based on patient’s body surface area is:
1) 199 g. to 238 g. (BSA 1.35 to 1.45)
OR
2) 239 g. to 284 g. (BSA 1.46 to 1.55)
OR
3) 285 g. to 349 g. (BSA 1.56 to 1.69)
OR
4) 350 g. or more.

Additional Information Required for Review of Reduction Mammoplasty:
1. History and findings on physical examination, supported by copies of contemporaneous office
medical records that document medical condition and functional deficit(s), and include as
indicated the details of duration, treatments, and responses (a separate letter summarizing case
will not satisfy the requirement);
2. Preoperative photograph(s), frontal and lateral views; and
3. Documentation that those 40 years of age and older have had mammogram negative for cancer
within a year of the date of the planned reduction mammoplasty.

Specific Guidelines: Mastectomy, Male
Mastectomy is surgery to remove breast tissue. Breast surgery may be considered clinically appropriate
when breast tissue is the cause of pain, or is related to specified conditions. Mastectomy for
asymptomatic individuals is typically considered cosmetic.

Some men and boys have excess adipose tissue, or gynecomastia, on their chests that mimics the
appearance of breasts. True gynecomastia is the abnormal growth of benign glandular breast tissue in
males resulting in firm, tender breast tissue. The pathophysiological process of true gynecomastia during
adolescence involves an imbalance between free estrogen and free androgen activity within the breast
tissue. During mid-to-late puberty, more estrogen may be produced by the testes and peripheral tissues
before testosterone secretion reaches adult levels, resulting in pubertal gynecomastia. In adolescent
boys, the condition is often a source of distress, but for the large majority of pubescent boys (70%)
whose gynecomastia is not due to obesity, the breast tissue is considered a normal part of male
adolescence and shrinks or disappears within a couple of years. Gynecomastia in older males can be
caused by several disorders affecting the endocrine system, by hormonal imbalances secondary to liver
Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment. Payment
is based on the member having active coverage, benefits and policies in effect at the time of service.

disease, as side effects of prescription drugs, by illicit drugs, by tumors, or as a part of the aging process.
Frequently, treating the underlying condition or changing medications will resolve the gynecomastia.

Pseudo gynecomastia is the accumulation of adipose tissue, removal of which is considered cosmetic
surgery.

Mastectomy for males age 18 years and younger may be considered clinically appropriate when it is
being performed to remove breast tissue in circumstances where all of the following criteria are met:
1. Patient has a disc-shaped mass of mobile, rubbery-feeling glandular tissue (not fatty tissue)
beneath the nipple and areolar area at least four (4) cm in diameter confirmed by clinical exam or
mammography, either unilateral or bilateral;
AND
2. Patient has pain or tenderness directly related to the breast tissue which has a clinically
significant impact upon activities of daily living and has been refractory to a trial of analgesics
and/or anti-inflammatory agents for 3 months;
AND
3. Patient has completed a 24 month period of clinical observation to allow for resolution of
excessive breast tissue as the patient matures;
AND
4. Patient has been evaluated by an endocrinologist and appropriate diagnostic evaluation has been
completed for presence of conditions that may be associated with gynecomastia, such as side
effect of numerous drugs known to cause gynecomastia (e.g., marijuana, cimetidine, anabolic
steroids).

NOTE: Mastectomy for gynecomastia is generally not considered clinically appropriate for any of the
following:
1. Surgical treatment for males with breast enlargement solely related to obesity (pseudo-
gynecomastia);
2. Surgical treatment for asymptomatic gynecomastia related to aging;
3. Cosmetic surgery performed primarily to improve appearance or self esteem; and
4. Surgical treatment if the gynecomastia is due to non-prescribed or illegal drug use.

Reduction mammoplasty for males over age 18 years is considered clinically appropriate when it is being
performed to remove breast tissue in circumstances where all of the following are met:
1. Gynecomastia has persisted for more than two (2) years and is documented in the physician’s
office records;
AND
2. Grade II, III or IV gynecomastia, per the “Gynecomastia Scale” used by the American Society of
Plastic Surgeons;
AND
3. Patient has been evaluated by an endocrinologist and appropriate diagnostic evaluation has been
done for conditions with which gynecomastia may be associated;
AND
4. One of the following:
a. Any proven or suspected malignancy;
OR
b. Continuous intractable breast pain refractory to six months of analgesic treatment, and
caused by true gynecomastia;
Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment. Payment
is based on the member having active coverage, benefits and policies in effect at the time of service.

 
                           OR
                        c. For gynecomastia related to prescription drug use, where:
                               1). Reversible side effects of a drug have been ruled out or it has been determined
                               that the causative drug cannot be discontinued;
                               OR
                               2). Persistent gynecomastia after the causative drug has been discontinued or
                               adjusted.

                     Gynecomastia	
  Scale	
  used	
  by	
  the	
  American	
  Society	
  of	
  Plastic	
  Surgeons	
  
              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	
  
                                distinct	
  from	
  the	
  chest	
  with	
  skin	
  redundancy	
  present	
  
             Grade	
  IV	
      Marked	
  breast	
  enlargement	
  with	
  skin	
  redundancy	
  and	
  feminization	
  of	
  the	
  breast	
  

Additional Information Required for Review of Male Mastectomy:
History submitted with the request must clearly document the indication for the requested procedure.

Specific Guidelines: Ptosis Surgery
The following procedures may be considered clinically appropriate when the criteria described below are
met:
  I.    Blepharoplasty (surgery to remove excess skin and fatty tissue around the eyes):
           A. To correct prosthesis difficulties in an anophthalmia socket; or
           B. To remove excess tissue of the upper eyelid causing functional visual impairment when
               photographs in straight gaze show eyelid tissue resting on or pushing down on the eye
               lashes (Note: excess tissue beneath the eye rarely obstructs vision, so the lower lid
               blepharoplasty is generally not clinically appropriate for this indication); or
           C. To repair defects predisposing to corneal or conjunctival irritation:
                   • Corneal exposure
                   • Ectropion (eyelid turned outward)
                   • Entropion (eyelid turned inward)
                   • Pseudotrichiasis (inward misdirection of eyelashes caused by entropion); or
           D. To relieve painful symptoms of blepharospasm; or
           E. To treat peri-orbital sequelae of thyroid disease and nerve palsy, and peri-orbital sequelae
               of other nerve palsy (e.g., the oculomotor nerve).

                 Note: Canthoplasty (surgery to tighten the muscles or ligaments that provide support to the outer
                 corner of the eyelid) may be considered clinically appropriate as part of a blepharoplasty
                 procedure to correct eyelids that sag so much that they pull down the upper eyelid so that vision
                 is obstructed.

       II.       Ptosis (drooping of one or both upper eyelids) also known as blepharoptosis repair for laxity of the
                 muscles of the upper eyelid causing functional visual impairment when photographs in straight

Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment. Payment
is based on the member having active coverage, benefits and policies in effect at the time of service.

To determine if a service or procedure requires prior authorization, CMAP Providers may refer to the Benefit and Authorization Grids summaries
on www.huskyhealth.com by clicking here. For a definitive list of benefits and service limitations, CMAP Providers may access the CMAP
provider fee schedules and regulations at www.ctdssmap.com.

gaze show the margin reflex difference (distance from the upper lid margin to the reflected
corneal light reflex at normal gaze) of 2mm or less.

III. Brow ptosis repair for laxity of the forehead muscles causing functional visual impairment when
photographs show the eyebrow below the sub-orbital rim.

IV. Eyelid ectropion or entropion repair for corneal or conjunctival injury due to ectropion, entropion or
trichiasis.

NOTE: Visual field testing is not routinely necessary to determine the presence of excess upper
eyelid skin, upper eyelid ptosis, or brow ptosis. Each of these three (3) components can be
present alone or in any combination, and each may require correction. If both a blepharoplasty
and ptosis repair are requested, two (2) photographs may be necessary to demonstrate the need
for both procedures: One (1) photograph should show the excess skin above the eye resting on
the eyelashes, and a 2nd photograph should show persistence of lid lag, with the upper eyelid
crossing or slightly above the pupil margin, despite lifting the excess skin above the eye off of the
eyelids with tape. If all three (3) procedures (i.e., blepharoplasty, blepharoptosis repair, and brow
ptosis repair) are requested, three (3) photographs may be necessary.

V. Surgical correction of congenital ptosis to allow proper visual development and prevent amblyopia
in infants and children with moderate to severe ptosis interfering with vision. Surgery is
considered cosmetic if performed for mild ptosis that is only of cosmetic concern. Photographs
must be available for review to document that the skin or upper eyelid margin obstructs a portion
of the pupil.

PROCEDURE
Prior authorization for surgical procedures that are either reconstructive or cosmetic is required.
Requests for coverage will be reviewed in accordance with procedures in place for reviewing requests for
surgical procedures. Coverage determinations will be based upon a review of requested and/or
submitted case-specific information. Individual consideration is always given to the member and their
specific clinical needs when determining coverage of services.

Information Required for Review:
1. Fully completed State of Connecticut, Department of Social Services Outpatient Prior
Authorization Request form;
2. Diagnosis;
3. Clinical information supporting the need for requested services to include medical history, clinical
indication(s) for requested procedure(s) and the function that will be improved or restored;
4. Information specific to requested procedure(s) as indicated in the policy section of this document;
and
5. Other information as requested.

EFFECTIVE DATE
This Policy is effective for prior authorization requests for reconstructive and cosmetic procedures for
HUSKY Health Program members on or after July 1, 2013.
Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment. Payment
is based on the member having active coverage, benefits and policies in effect at the time of service.

 

LIMITATIONS
N/A

CODES:
Code   Description
15820 Blepharoplasty, lower eyelid
15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad
15822 Blepharoplasty, upper eyelid
15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid
15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical
       panniculectomy
19300 Mastectomy for gynecomastia
19318 Reduction mammoplasty
19328 Removal of intact mammary implant
19330 Removal of mammary implant material
49560 Repair initial incisional or ventral hernia; reducible
49565 Repair recurrent incisional or ventral hernia; reducible
49654 Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed);
       reducible
49656 Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when
       performed); reducible
67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)
67901 Repair of blepharoptosis; frontalis muscle technique with suture or other material (e.g., banked
       fascia)
67902 Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes
       obtaining fascia)
67903 Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach
67904 Repair of blepharoptosis (tarso) levator resection or advancement, external approach
67906 Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia)
67908 Repair of blepharoptosis; conjunctivo-tarso- Muller’s muscle-levator resection (e.g., Fasanella-
       Servat type)
67909 Reduction of overcorrection of ptosis
67914 Repair of ectropion; suture
67915 Repair of ectropion; thermo-cauterization
67916 Repair of ectropion; excision tarsal wedge
67917 Repair of ectropion; extensive (e.g., tarsal strip operations)
67921 Repair of entropion; suture
67922 Repair of entropion; thermocauterization
67923 Repair of entropion; excision tarsal wedge
67924 Repair of entropion; extensive (e.g., tarsal strip or capsulopalpebral fascia repairs operation)
67950 Canthoplasty (reconstruction of canthus)

Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment. Payment
is based on the member having active coverage, benefits and policies in effect at the time of service.

To determine if a service or procedure requires prior authorization, CMAP Providers may refer to the Benefit and Authorization Grids summaries
on www.huskyhealth.com by clicking here. For a definitive list of benefits and service limitations, CMAP Providers may access the CMAP
provider fee schedules and regulations at www.ctdssmap.com.

DEFINITIONS
1. Current Procedural Terminology (CPT): The most recent edition of a listing, published by the
American Medical Association, of descriptive terms and identifying codes for reporting medical
services performed by providers.
2. Gynecomastia: Gynecomastia is the abnormal growth of benign glandular breast tissue in males
resulting in firm breast tissue.
3. HUSKY A: Connecticut children and their parents or a relative caregiver; and pregnant women may
qualify for HUSKY A (also known as Medicaid). Income limits apply.
4. HUSKY B: Uninsured children under the age of 19 in higher income households may be eligible for
HUSKY B (also known as the Children’s Health Insurance Program) depending on their family
income level. Family cost-sharing may apply.
5. HUSKY C: Connecticut residents who are age 65 or older or residents who are ages 18-64 and who
are blind, or have another disability, may qualify for Medicaid coverage under HUSKY C (this includes
Medicaid for Employees with Disabilities (MED-Connect), if working). Income and asset limits apply.
6. HUSKY D: Connecticut residents who are ages 19-64 without dependent children and who: (1) do
not qualify for HUSKY A; (2) do not receive Medicare; and (3) are not pregnant, may qualify for
HUSKY D (also known as Medicaid for the Lowest-Income populations).
7. HUSKY Health Program: The HUSKY A, HUSKY B, HUSKY C, HUSKY D and HUSKY Limited
Benefit programs, collectively.
8. HUSKY Limited Benefit Program or HUSKY, LBP: Connecticut’s implementation of limited
health insurance coverage under Medicaid for individuals with tuberculosis or for family planning
purposes and such coverage is substantially less than the full Medicaid coverage.
9. HUSKY Plus Physical Program (or HUSKY Plus Program): A supplemental physical health
program pursuant to Conn. Gen. Stat. § 17b-294, for medically eligible members of HUSKY B in
Income Bands 1 and 2, whose intensive physical health needs cannot be accommodated within
the HUSKY Plan, Part B.
10. Medically Necessary or Medical Necessity: (as defined in Connecticut General Statutes § 17b-
259b) Those health services required to prevent, identify, diagnose, treat, rehabilitate or
ameliorate an individual's medical condition, including mental illness, or its effects, in order to
attain or maintain the individual's achievable health and independent functioning provided such
services are: (1) Consistent with generally-accepted standards of medical practice that are
defined as standards that are based on (A) credible scientific evidence published in peer-
reviewed medical literature that is generally recognized by the relevant medical community, (B)
recommendations of a physician- specialty society, (C) the views of physicians practicing in
relevant clinical areas, and (D) any other relevant factors; (2) clinically appropriate in terms of
type, frequency, timing, site, extent and duration and considered effective for the individual's
illness, injury or disease; (3) not primarily for the convenience of the individual, the individual's
health care provider or other health care providers; (4) not more costly than an alternative
service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic
results as to the diagnosis or treatment of the individual's illness, injury or disease; and (5) based
on an assessment of the individual and his or her medical condition.

11. Prior Authorization: A process for approving covered services prior to the delivery of the service
or initiation of the plan of care based on a determination by CHNCT as to whether the requested
Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment. Payment
is based on the member having active coverage, benefits and policies in effect at the time of service.

service is medically necessary.

ADDITIONAL RESOURCES AND REFERENCES
• Adamson PA, Strecker HD. Transcutaneous lower blepharoplasty. Facial Plast Surg.
1996;12(2):171-183.
• Aetna Clinical Policy Bulletin: (2014, November). Ptosis Surgery, Policy Number: 0084.
Retrieved from: http://www.aetna.com/cpb/medical/data/1_99/0084.html . Last Accessed,
November 14, 2014.
• American Academy of Ophthalmology. Functional indications for upper and lower eyelid
blepharoplasty. Ophthalmology. 1995;102(4):693-695
• American Academy of Ophthalmology. Laser blepharoplasty and skin resurfacing.
Ophthalmology. 1998;105(11):2154-2159.
• American Medical Association, Current Procedural Terminology Manual: 2014
• American Optometric Association. Care of the patient with amblyopia. Optometric Clinical
Practice Guideline No. 4. 2nd ed. St. Louis, MO: American Optometric Association; 1997.
• American Society of Plastic and Reconstructive Surgeons. Blepharoplasty Position Paper.
Arlington Heights, IL: American Society of Plastic and Reconstructive Surgeons, Inc.; October
1990.
• Apfelberg DB. Summary of the 1997 ASAPS/ASPRS Laser Task Force Survey on laser
resurfacing and laser blepharoplasty. American Society for Aesthetic Plastic Surgery. American
Society of Plastic and Reconstructive Surgeons. Plast Reconstr Surg. 1998;101(2):511-518.
• Barnes JA, Bunce C, Olver JM. Simple effective surgery for involutional entropion suitable for the
general ophthalmologist. Ophthalmology. 2006;113(1):92-96.
• Baylis HI, Goldberg RA, Kerivan KM, et al. Blepharoplasty and periorbital surgery. Dermatol Clin.
1997;15(4):635-647.
• Bedran EG, Pereira MV, Bernardes TF. Ectropion. Semin Ophthalmol. 2010;25(3):59-65.
• Benatar M, Kaminski H. Medical and surgical treatment for ocular myasthenia. Cochrane
Database Syst Rev. 2006;(2):CD005081.
• Biesman BS. Blepharoplasty. Semin Cutan Med Surg. 1999;18(2):129-138.
• Bembo SA, Carlson HE. Gynecomastia: its features, and when and how to treat it. Cleveland
Clinic Journal of Medicine 2004; 71(6):511-517.
• Braunstein, N Engl J Med 2007; 357(12): 1229-1237.
• Broujerdi JA. Aesthetic surgery of the orbits and eyelids. Oral Maxillofac Surg Clin North Am.
2012;24(4):665-695.
• Burnstine MA, Putterman AM. Upper blepharoplasty: A novel approach to improving progressive
myopathic blepharoptosis. Ophthalmology. 1999;106(11):2098-2100.
• Cahill KV, Bradley EA, Meyer DR, et al. Functional indications for upper eyelid ptosis and
blepharoplasty surgery: A report by the American Academy of Ophthalmology. Ophthalmology.
2011;118(12):2510-2517.
• Cassar K, Munro A. Surgical treatment of incisional hernia. Br J Surg. 2002; 89(5):534-545.
• Chang S, Lehrman C, Itani K, Rohrich RJ. A systematic review of comparison of upper eyelid
involutional ptosis repair techniques: Efficacy and complication rates. Plast Reconstr Surg.
2012;129(1):149-157.

• Dailey RA, Saulny SM. Current treatments for brow ptosis. Curr Opin Ophthalmol.
2003;14(5):260-266.
Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment. Payment
is based on the member having active coverage, benefits and policies in effect at the time of service.

 
       •   Davies RP. Surgical options for eyelid problems. Aust Fam Physician. 2002;31(3):239-245.
       •   de Figueiredo AR. Blepharoptosis. Semin Ophthalmol. 2010;25(3):39-51.
       •   Devalia HL, Layer GT. Current concepts in gynecomastia. Surgeon. 2009 Apr; 7(2):114-9.
       •   Eckman A, Dobs A. Drug-induced gynecomastia. Expert Opin Drug Saf. 2008 Nov; 7(6):691-702.
       •   Edmonson BC, Wulc AE. Ptosis evaluation and management. Otolaryngol Clin North Am.
           2005;38(5):921-946.
       •   Fedok FG, Perkins SW. Transconjunctival blepharoplasty. Facial Plast Surg. 1996;12(2):185-195.
       •   Fong KC, Mavrikakis I, Sagili S, Malhotra R. Correction of involutional lower eyelid medial
           ectropion with transconjunctival approach retractor plication and lateral tarsal strip. Acta
           Ophthalmol Scand. 2006;84(2):246-249.
       •   Friedland JA, Jacobsen WM, TerKonda S. Safety and efficacy of combined upper
           blepharoplasties and open coronal browlift: A consecutive series of 600 patients. Aesthetic Plast
           Surg. 1996;20(6):453-462.
       •   Frueh BR, Musch DC, McDonald HM. Efficacy and efficiency of a small-incision, minimal
           dissection procedure versus a traditional approach for correcting aponeurotic ptosis.
           Ophthalmology. 2004;111(12):2158-2163.
       •   Gabriel SE, Woods JE, O’Fallon WM, et al. Complications leading to surgery after breast
           implantation. N Eng J Med. 1997; 336:677-682.
       •   Gündisch O, Vega A, Pfeiffer MJ, Hintschich C. The significance of intraoperative measurements
           in acquired ptosis surgery. Orbit. 2008;27(1):13-18.
       •   Hatt S, Antonio-Santos A, Powell C, Vedula SS. Interventions for stimulus deprivation amblyopia.
           Cochrane Database Syst Rev. 2006:(3):CD005136.
       •   Ho SF, Pherwani A, Elsherbiny SM, Reuser T. Lateral tarsal strip and quickert sutures for lower
           eyelid entropion. Ophthal Plast Reconstr Surg. 2005;21(5):345-348.
       •   Holmich LR, Fryzek JP, Kjoller K, et al. The diagnosis of silicone breast implant rupture: clinical
           findings compared with findings at Magnetic resonance imaging. Ann Plast Surg. 2005;
           54(6):583-589.
       •   Hughes KC. Ventral hernia repair with simultaneous panniculectomy. Ann Surg. 1996; 62(8):678-
           681.
       •   Januszkiewicz JS, Nahai F. Transconjunctival upper blepharoplasty. Plast Reconstr Surg.
           1999;103(3):1015-1019.
       •   Kikkawa DO, Kim JW. Lower-eyelid blepharoplasty. Int Ophthalmol Clin. 1997;37(3):163-178.
       •   Kikkawa DO, Miller SR, Batra MK, et al. Small incision nonendoscopic browlift. Ophthal Plast
           Reconstr Surg. 2000;16(1):28-33.
       •   Kumar S, Kamal S, Kohli V. Levator plication versus resection in congenital ptosis - a prospective
           comparative study. Orbit. 2010;29(1):29-34.
       •   Lee MS. Overview of ptosis. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed
           October 2013.
       •   Lessner AM, Fagien S. Laser blepharoplasty. Semin Ophthalmol. 1998;13(3):90-102.
       •   Mahe E. Lower lid blepharoplasty-The transconjunctival approach: Extended indications.
           Aesthetic Plast Surg. 1998;22(1):1-8.
       •   McLaughlin JK, Lipworth L, Murphy DK, Walker PS. The safety of silicone gel-filled breast
           implants: a review of the epidemiologic evidence. Ann Plast Surg. 2007; 59(5) 569-580.
       •

       •   Meyer DR, Linberg JV, Powell SR, Odom JV. Quantitating the superior visual field loss
           associated with ptosis. Arch Ophthalmol. 1989;107(6):840-843.
Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment. Payment
is based on the member having active coverage, benefits and policies in effect at the time of service.

To determine if a service or procedure requires prior authorization, CMAP Providers may refer to the Benefit and Authorization Grids summaries
on www.huskyhealth.com by clicking here. For a definitive list of benefits and service limitations, CMAP Providers may access the CMAP
provider fee schedules and regulations at www.ctdssmap.com.

• Nahas FX, Augusto SM, Ghelfond C. Should diastasis recti be corrected? Aesth Plas Surg. 1997;
21(4):285-289.
• Nordt CA, DiVasta AD. Gynecomastia in adolescents. Curr Opin Pediatr. 2008 Aug; 20(4):375-
382.
• Older JJ. Ptosis repair and blepharoplasty in the adult. Ophthalmic Surg. 1995;26(4):304-308.
• Pastorek N. Upper-lid blepharoplasty. Facial Plast Surg. 1996;12(2):157-169.
• Rougraff PM, Tse DT, Johnson TE, Feuer W. Involutional entropion repair with fornix sutures and
lateral tarsal strip procedure. Ophthal Plast Reconstr Surg. 2001;17(4):281-287.
• Sakol PJ, Mannor G, Massaro BM. Congenital and acquired blepharoptosis. Curr Opin
Ophthalmol. 1999;10(5):335-339.
• Scuderi N, Chiummariello S, De Gado F, et al. Surgical correction of blepharoptosis using the
levator aponeurosis-Müller's muscle complex readaptation technique: A 15-year experience. Plast
Reconstr Surg. 2008;121(1):71-78.
• Shields M, Putterman A. Blepharoptosis correction. Curr Opin Otolaryngol Head Neck Surg.
2003;11(4):261-266.
• Stephenson CB. Upper-eyelid blepharoplasty. Int Ophthalmol Clin. 1997;37(3):123-132.

PUBLICATION HISTORY

Status Date Action Taken
Original Publication July 2013
Review June 2014 Clinical Quality Subcommittee
review. References updated.
These changes approved at the
June 23, 2014 Clinical Quality
Subcommittee meeting.
Review September 2014 Medical Management Review
Update to Reduction Mammoplasty
criteria indicating symptoms must
be present for at least one (1) year
and pain symptoms result in
functional deficits – Change
effective November 1, 2014.
Updates approved by DSS on
September 12, 2014.
Review November 2014 Medical Management Review
Added criteria, codes and
references for ptosis surgery.
Updates approved by DSS on
November 17, 2014.
Review December 2014 Clinical Quality Subcommittee
review. Changes approved at the
December 15, 2014 Clinical Quality
Subcommittee meeting.
Updated August 2015 Updated definitions for HUSKY A,
B, C and D programs at request of
Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment. Payment
is based on the member having active coverage, benefits and policies in effect at the time of service.

 
                                                                                              DSS.

Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment. Payment
is based on the member having active coverage, benefits and policies in effect at the time of service.

To determine if a service or procedure requires prior authorization, CMAP Providers may refer to the Benefit and Authorization Grids summaries
on www.huskyhealth.com by clicking here. For a definitive list of benefits and service limitations, CMAP Providers may access the CMAP
provider fee schedules and regulations at www.ctdssmap.com.

You can also read