This policy describes a variety of techniques addressing skin lesions and conditions.   Cosmetic, reconstructive and medically necessary uses of these techniques will be addressed.

Please see the following for additional information:

• ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
• MED.00017 Photodynamic Therapy
• MED.00063 Treatment of Acne Vulgaris Using Pulsed Dye Laser or Photodynamic Therapy
• CG-MED-27 Management of Rosacea
• CG-SURG-27 Gender Reassignment Surgery

Policy Statement

Medically Necessary:  In this policy, procedures are considered medically necessary if there is a significant physical functional impairment ANDthe procedure can be reasonably expected to improve the physical functional impairment. Some situations where various procedures are considered medically necessary are described below.

Reconstructive: In this policy, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect.  Some situations where various procedures are considered reconstructive are described below.

Cosmetic: In this policy, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation.  Cosmetic services are often described as those which are primarily intended to preserve or improve appearance. Some situations where various procedures are considered cosmetic are described below.

1. Chemical Peels

   Chemical peels vary by depth of treatment. More superficial treatments are referred to as epidermal peels or epidermal exfoliation. Medium or deep chemical peels are sometimes referred to as dermal peels.

   Chemical peels, including epidermal exfoliation(epidermal peels) or cryotherapy, are considered medically necessary for active acne when there is documented evidence of failure of a trial of topical retinoid treatment, topical and oral antibiotic therapy.

   Dermal peels are considered medically necessary  when there is documented evidence of 10 or more actinic keratoses or other pre-malignant skin lesions that have failed topical retinoid treatment, topical chemotherapeutic agents and cryotherapy.

   Chemical peels, either epidermal or dermal, are considered cosmetic/not medically necessary when used to treat photo-aged skin, wrinkles, acne scarring or uneven epidermal pigmentation.

2. Collagen Injections

   Collagen injections or implants are considered medically necessary when there is documented evidence of significant physical functional impairment and the treatment can be reasonably expected to improve the physical functional impairment.

   Collagen injections may be reconstructive in settings where there is significant abnormality after accidental injury, trauma, surgery or as the result of a treatment or congenital defect.

   Collagen injections or implants are considered cosmetic/not medically necessary when performed in the absence of a physical functional impairment and are performed solely to enhance appearance (i.e., lip enhancement procedures).

3. Dermabrasion

   Dermabrasion or salabrasion is considered medically necessary when there is documented evidence of the removal of 10 or more superficial basal cell carcinomas and pre-cancerous actinic keratoses that have failed topical retinoid treatment, topical chemotherapeutic agents and cryotherapy.

   Dermabrasion or salabrasion is considered cosmetic/not medically necessary when used to enhance appearance of the upper layer of the skin for acne, acne scars, uneven pigmentation or wrinkles.

4. Laser and Surgical Treatment of Acne Rosacea

   Surgical management of acne rosacea is considered medically necessary when the criteria below are met.

   • Laser and surgical treatment of rosacea is reserved for severe and refractory forms of rosacea, unresponsive to standard medical therapy.  Standard medical therapy includes an adequate trial of topical agents and/or oral agents (antibiotics). Documentation that the patient has undergone and received inadequate results with conservative management as well as preoperative photos documenting the clinical skin changes that are to be treated are required.
     • Severe permanent telangiectasia may be treated by electrosurgery, laser (pulsed dye V-beam, the 585 flash pump laser, KTP laser) or intense pulsed light (IPL) therapy.
     • Severe rhinophyma can be treated with a radiofrequency cutting current and a hockey puck adapter, carbon dioxide laser peel, or surgical shaving.

   The use of lasers or other surgical treatments for isolated telangiectasia or when the above criteria are not met is considered cosmetic/not medically necessary.

5. Treatment of Keloids and Scar Revision

   Treatment of keloids is considered medically necessary when there is documented evidence of significant physical functional impairment related to the keloid AND the treatment can be reasonably expected to improve the physical functional impairment. Treatment decisions in this setting must weigh the risk of causing additional keloids.

   Treatment of keloids may be reconstructive when the keloids themselves produce significant anatomic variance. Treatment decisions in this setting must weigh the risk of causing additional keloids.

   Scar revision is considered medically necessary when there is documented evidence of significant physical functional impairment related to the scar AND the treatment can be reasonably expected to improve the physical functional impairment. Treatment decisions in this setting must weigh the risk of causing additional scars.

   Scar revision may be reconstructive in settings where there is significant anatomic variance after accidental injury, surgery or as the result of a treatment.

   Treatment of keloids is considered cosmetic/not medically necessary when done in the absence of a significant physical functional impairment or significant anatomic variation.

   Scar revisions are considered cosmetic/not medically necessary when done in the absence of a significant physical functional impairment or significant anatomic variation and therefore solely to improve appearance.

6. Tattoos (Application): 

   Tattooing of skin may be considered medically necessary when done as part of a medically necessary therapeutic process (i.e., radiation therapy, or as a result of a breast reconstruction).

7. Photodynamic Therapy with ALA

   Photodynamic therapy (PDT) with topical 5-ALA is discussed in MED.00017 Photodynamic Therapy.

8. Injection of L-Poly-L-lactic acid

   The injection of poly-L-lactic acid, also known as Sculptra™, is considered reconstructive when used to restore appearance after treatment for a disease, injury or congenital abnormality.

9. Port Wine Stain

   Treatment of port wine stain with laser or other methods is considered reconstructive when used to restore appearance resulting from a congenital anomaly.

10. Hair Procedures

    Hairplasty (hair transplant) for male pattern alopecia or any alopecia is considered cosmetic/not medically necessary under all conditions.

    The permanent removal of hair, including, but not limited to, the use of lasers, electrolysis, and waxing, is considered cosmetic/not medically necessary for all indications, including, but not limited to hirsutism.

    The temporary removal of hair by any method, including, but not limited to, lasers, electrolysis, and waxing is considered cosmetic/not medically necessary under all circumstances.

11. Other Cosmetic Skin Procedures

    Laser skin resurfacing is considered cosmetic/not medically necessary when used to create smoother skin and remove wrinkles.

    Removal or excision of a tattoo is considered cosmetic/not medically necessary for all circumstances.

    Treatment of telangiectasias (spider veins) is considered cosmetic/not medically necessary.

Rationale

Concepts of Medical Necessity, Reconstructive and Cosmetic

The coverage eligibility of medical and surgical therapies to treat musculoskeletal abnormalities is often based on a determination of whether the abnormality is considered medically necessary, reconstructive or cosmetic in nature. In many instances the concept of reconstructive overlaps with the concept of medical necessity. For example, services intended to correct a significant physical functional impairment as a result of trauma will be considered medically necessary and thus eligible for coverage, regardless of the contract language pertaining to reconstructive services, unless some other exclusion applies. Generally, reconstructive is often taken to mean that the service “returns the patient to whole” as a result of a congenital anomaly, disease or other condition including post trauma or post therapy, while cosmetic generally describes improving a physical appearance that would be considered within normal human anatomic variation. Categories of conditions without associated functional impairment that may be included as reconstructive, include or may be due to the following: a) surgery, b) accidental trauma or injury, c) diseases, d) congenital anomalies, e) severe anatomic variants, and f) chemotherapy. 

Treatment of Acne Rosacea

The treatment of acne rosacea is dictated by the severity of the disease.  Because the diagnosis of acne rosacea is made on the basis of clinical features several of which may be common to other skin conditions, differentiation of rosacea from other diseases/conditions may be required.  Isolated telangectasia in the absence of other signs and symptoms are not diagnostic of rosacea.

When avoidance of common environmental (sun exposure or temperature changes) or dietary (alcohol, spicy foods) triggers is inadequate oral antibiotics or topical agents (antibiotics, azelaic acid, isotretinoin, sulfacetamide) are employed.  In general, a 12-week trial of topical treatment is used to assess response.  Laser treatment and surgical intervention is reserved for cases which are unresponsive to other treatments.

Background/Overview

Chemical peels are a group of skin procedures used to treat a wide variety of skin conditions including pre-cancerous skin lesions, aged skin, wrinkles, acne, acne scarring and uneven epidermal pigmentation.  One of several chemical solutions is used, (eg. glycolic acid, salicylic acid, lactic acid) which are applied to the skin causing it to "blister" and eventually peel off.  The new, regenerated skin is usually free of any pre-malignant lesions and is generally smoother and less wrinkled than the original skin.

Collagen injections and implants involve the use of collagen; a protein found in the skin, to make a body part, such as the lips or chin, appear fuller.  This procedure involves either the injection of raw collagen or the surgical implantation of a pre-formed collagen implant under the surface of the skin.  This procedure may be used to restore the appearance or physical function after accidental injury.  It may also be used to enhance appearance.

Dermabrasion, or surgical skin planing, is a treatment of pre-cancerous skin lesions and acne, which also has cosmetic uses.  During this procedure a physician freezes the patient’s skin and then mechanically removes or "sands" the skin to eliminate any lesions to improve contour to achieve a rejuvenated appearance.  Salabrasion although, basically the same technique uses salt impregnated gauze pads to remove the upper layers of skin.

Excessive hair growth on the face or body it is known as hirsutism.  While this occurs in both men and women, it is usually only viewed as problematic for women.  There are many ways to remove unwanted hair, including temporary measures such as waxing, shaving, or using depilatory creams.  There are also more permanent methods such as electrolysis or laser hair

removal.  Electrolysis removes hair permanently by delivering a small electrical current through a needle inserted into the hair follicle.  This current destroys the follicle and prevents regrowth.  Laser techniques use concentrated beams of light to accomplish this.  Neither sporadic areas of unwanted hair nor hirsutism have been associated with any health-related problems and treatment is considered cosmetic.

Alopecia is the medical term for hair loss.  The most common type of hair loss is androgenetic alopecia or male pattern baldness. It is typically permanent, may occur in both men and women and is hereditary.  There are no health-related ramifications of this condition.  The available treatments for alopecia are hairpieces, medications to promote hair growth, and hairplasty.  Hairplasty, commonly referred to as hair transplant, involves taking tiny plugs of skin, containing one to several hairs, from the back or side of the scalp and re-implanting them into the bald scalp sections.  Several transplant sessions may be needed as hereditary hair loss progresses with time.

Keloids are an overgrowth of scar tissue in response to skin injury causing a raised, hardened section of skin.  Keloids occur from such skin injuries as surgical incisions, traumatic wounds, vaccination sites, burns, chicken/pox, acne or even minor scratches.  They are fairly common in young women and African Americans.  Keloids require no treatment unless they cause functional problems.  Often keloids recur (sometimes larger than before) after they have been removed.

Laser skin resurfacing involves using a strong laser to literally burn away unwanted skin lesions such as pre-cancerous lesions, acne scars, or wrinkles.

Acne vulgaris is the most common form of acne, occurring in an estimated 85% of the adolescent population in the United States.  While, for the most part, the manifestations of acne vulgaris are temporary, severe cases may result in permanent scarring.  There are several local factors that contribute to the development of acne vulgaris, including blocked hair follicles, enlargement of specific skin glands, over production of skin glands products that promote bacterial growth, and inflammatory responses to bacterial overgrowth.  Other less common causes include hormonal imbalance and some medications.  Treatment of acne vulgaris is approached step-wise, beginning with the least invasive and risky therapies including topical medications (applied to the skin), followed by oral medications alone or in combination.  Topical medications include antibiotics, retinoids, benzoyl peroxide, salicylic acid, and others. Oral medications used are antibiotics, isotretinoin, and in select cases oral contraceptives.

Some medical conditions may result in a condition called lipoatrophy, characterized by facial wasting of fat under the skin of the face and other parts of the body.  Lipoatrophy results in a gaunt or wasted appearance.  There are no health problems related specifically to this condition.  A reconstructive treatment involving the injection of poly-L-lactic acid is available to address this.  This material is a biodegradable synthetic substance used in the manufacture of absorbable stitches and implantable medical devices.  Sculptra™ is an injectable form of this material injected under the skin of a patient with lipoatrophy to restore a more normal facial or body contour.

Port wine stains (large congenital hemangiomas) are a type of birthmark consisting of superficial and deep dilated capillaries in the skin that produce a reddish or purplish discoloration.  This condition is present at birth and usually does not pose any health problems.  Many treatments have been tried for this condition but the advent of laser treatment has had the greatest impact.  

Scar revision is a surgical procedure that is intended to change a scar resulting from injury or surgery.  This involves surgery on the scarred area, removal of the scar tissue and re-closing the wound in a new configuration that either will not interfere with function or has a more acceptable appearance.

Skin lesion is a nonspecific term referring to any change in the skin surface.  While some skin lesions represent diseases, which require medical treatment, others do not.

Tattooing is the permanent injection of ink under the skin for decorative or medical purposes.  Tattoos are usually permanent and cannot be removed without intervention.  The removal of tattoos may be done with laser treatments, dermabrasion, or actual surgical removal. While tattoo removal is usually effective, some scarring or skin discoloration may result from the procedure.

Telangiectasias, also known as spider veins, are abnormally dilated blood vessels associated with a number of diseases such as ataxia-telangiectasia and scleroderma, but are mostly benign in nature and due to hereditary or unknown factors. Spider veins may appear anywhere on the body but are most commonly noted on the arms, face and legs. Treatment for spider veins may be done with laser therapy.

Definitions

Actinic keratoses: (also referred to as solar keratoses) are common sun-exposure related skin lesions microscopically involving the epidermis alone but with the potential ultimately to progress to invasive cancer (squamous cell carcinoma) in a small percentage of cases (variously estimated from 0.1% to 20%).

Acne rosacea: a common dermatologic condition characterized by symptoms of facial flushing and a spectrum of clinical signs, including erythema, telangiectasia, and inflammatory papular or pustular eruptions resembling acne.  Rosacea affects the central flush/blush areas of the face (i.e., forehead, nose, cheeks, chin), although ocular disease and extrafacial lesions are well-recognized features.  Intermittent facial flushing is a central feature of the disease.  Permanent telangiectasia may result. Sebaceous hyperplasia, fibrosis, and edema (Rhinophyma) characterize more severe forms of the disease

Acne vulgaris: the most common form of acne; most commonly found in adolescents but may be seen in adults as well

Collagen injection or implants: the injection of raw collagen, a naturally occurring substance that gives skin its elasticity, or the implantation of an implant made of collagen, to create a fuller appearance to the skin

Chemical peels: a group of medical procedures using various chemicals to remove the outer layers of the skin

Dermabrasion or salabrasion: a group of medical procedures using physical scrubbing methods to remove the outer layer of the skin

Electrolysis:  a procedure designed to permanently remove unwanted hair

Hairplasty: a surgical procedure designed to transplant or implant hair to areas where hair has been lost, such as in the case of male baldness

Hirsutism: excessive hairiness

Keloids: a condition where a scar becomes raised above the plain of normal skin and has a hardened texture

Laser skin resurfacing: a group of medical procedures using laser light methods to remove the outer layer of the skin

Port wine stain: a large congenital hemangioma which is visible as a mark on the skin that resembles port wine in its rich ruby red color; these marks are due to an abnormal aggregation of capillaries in a portion of the skin 

Poly-L-lactic acid (also known as Sculptra™): a biodegradable substance that can be injected under the skin to restore the appearance of patients who have lost subcutaneous fat due to illness; this substance may also be used for cosmetic purposes to enhance a person’s appearance

Scar revisions: a procedure that involves surgically removing scar tissue and re-closing the wound in order to repair cosmetic or functional problems

Significant physical functional impairment: limits on normal physical functioning that may include, but are not limited to, problems with communication, respiration, eating, swallowing, visual impairments, skin integrity, distortion of nearby body parts, or obstruction of an orifice.   The cause of the physical functional impairment may be pain, structural integrity, congenital anomalies or other factors.  Significant physical functional impairment excludes social, emotional, and psychological impairments or potential impairments.

Telangiectasias: commonly called spider veins; a condition characterized by small, red or blue spider-web marks close to the surface of the skin caused by permanent dilation of small blood vessels.  These blood vessels look like thick red lines and may occur in any part of the body, but most commonly are seen on the legs, torso and face.

Coding

The following codes for treatments and procedures applicable to this policy are included below for informational purposes.   Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Chemical Peels, Cryotherapy, Chemosurgery

Services may be Medically Necessary, when criteria are met:

CPT

ICD-9 Procedure

ICD-9 Diagnosis

When services are Cosmetic/Not Medically Necessary:

For the procedure codes listed above, when criteria are not met, for all other diagnoses not listed; or when the code describes a procedure indicated in the Policy section as cosmetic/not medically necessary.

Collagen Injections

Services may be Medically Necessary when criteria are met:

CPT

ICD-9 Procedure

ICD-9 Diagnosis

When services are Reconstructive:

For procedure codes above when criteria for reconstructive services are met without significant physical functional impairment; or when the code describes a procedure indicated in the policy section as reconstructive.

When services are Cosmetic/Not Medically Necessary:

For the procedure codes listed above, when criteria are not met for medically necessary or reconstructive services (in the absence of significant physical functional impairment); or when the code describes a procedure indicated in the Policy section as cosmetic/not medically necessary.

Dermabrasion, Abrasion

When services are Medically Necessary:

CPT

ICD-9 Procedure

ICD-9 Diagnosis

When services are Cosmetic/Not Medically Necessary:

For the procedure codes listed above, when criteria are not met, for all other diagnoses not listed; or when the code describes a procedure indicated in the Policy section as cosmetic/not medically necessary.

Laser /Surgical treatment of Acne Rosacea

Services may be Medically Necessary when criteria are met:

CPT

ICD-9 Diagnosis

When services are Cosmetic/Not Medically Necessary:

For the procedure and diagnosis codes listed above, when criteria are not met; or when the code describes a procedure indicated in the Policy section as cosmetic/not medically necessary.

Keloids/Scar Revision

Services may be medically necessary when criteria are met:

CPT

ICD-9 Procedure

ICD-9 Diagnosis

When services are Reconstructive: 

For the procedure and diagnosis codes above when criteria for reconstructive services are met without significant physical functional impairment; or when the code describes a procedure indicated in the policy section as reconstructive.

When services are Cosmetic/Not Medically Necessary:

For the procedure and diagnosis codes listed above, when criteria are not met; or when the code describes a procedure indicated in the Policy section as cosmetic/not medically necessary.

Tattooing (application and removal)

When services are Medically Necessary:

CPT

ICD-9 Procedure code

ICD-9 Diagnosis

When services are Cosmetic/Not Medically Necessary:

For the procedure codes listed above for all other indications; or or when the code describes a procedure indicated in the Policy section as cosmetic/not medically necessary.

Services are Medically Necessary:

CPT

ICD-9 Diagnosis

When services are Cosmetic/Not Medically Necessary:

For the procedure code listed above, for all other indications; or when the code describes a procedure indicated in the Policy section as cosmetic/not medically necessary.

Injecton of Poly-L-lactic Acid

When services may be reconstructive when criteria are met:

HCPCS

ICD-9 Diagnosis

Services are cosmetic/not medically necessary:
For the procedure code listed above when criteria are not met; or when the code describes a procedure indicated in the policy section as cosmetic/not medically necessary.

Port Wine Stain

When services are reconstructive:

CPT

ICD-9 Diagnosis

Other

When services are Cosmetic/Not Medically Necessary:

CPT

ICD-9 Diagnosis

References

Peer Reviewed Publications:

1. Ayhan S, Baran CN, Yavuzer R, et al. Combined chemical peeling and dermabrasion for deep acne and posttraumatic scars as well as aging face. Plast Reconst Surg. 1998; 102(4):1238-46.
2. Barnaby JW, Styles AR, Cockerell CR. Actinic keratoses. Differential diagnosis and treatment. Drugs Aging. 1997; 11(3):186-205.
3. Garcia GH, Neuburg M, Troy JL, et al. Periocular deep cutaneous basal cell carcinoma. Ophthal Plast Reconstr Surg. 1999; 15(6):393-5.
4. Hoeyberghs JL. Fortnightly review: cosmetic surgery. BMJ. 1999; 318:512-6.
5. Jiang SB, Levine VJ, Nehal KS, et al. Er:YAG laser for the treatment of actinic keratoses. Dermatol Surg. 2000; 26(5):437-40.
6. Otley, CC, Roenigk, RK. Medium-depth chemical peeling. Semin Cutan Med Surg. 1996; 15(3):145-154.
7. Quaedvlieg PJ, Tirsi E, Thissen MR, Krekels GA. Actinic keratosis: how to differentiate the good from the bad ones? Eur J Dermatol. 2006;16(4):335-9.
8. Roberts TL 3^rd, Ellis LB. In pursuit of optimal rejuvenation of the forehead; endoscopic brow lift with simultaneous carbon dioxide laser resurfacing. Plas Reconst Surg. 1998; 101(4):1075-84.
9. van Zuuren EJ, Graber MA, Hollis S, Chaudhry M, Gupta AK, Gover M. Interventions for rosacea. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD003262. DOI: 10.1002/14651858.CD003262.pub3.

1. American Academy of Dermatology Association. Guidelines of care for acne vulgaris management. 2006. Available at:  http://www.aad.org/NR/rdonlyres/FAD10239-F59B-486C-8082- 8545B54F59A/0/Acne_Guideline.pdf. Accessed on September 5, 2006.
2. American Academy of Dermatology Association. Guidelines of care for actinic keratoses.    http://www.aadassociation.org/Guidelines/actkeratoses.html Accessed on November 09, 2005. 
3. American Academy of Dermatology Association. Guidelines of care for soft tissue augmentation: collagen implants. J Am Acad Dermatol. 1996 Apr;34(4):698-702.Guidelines of care for soft tissue augmentation collagen implants.http://www.aadassociation.org/Guidelines/softcollagen.html Accessed on November 09, 2005.
4. Centers for Medicare and Medicaid Services. National Coverage Determination for Laser Procedures. NCD #140.5.  Effective May 1, 1997.  http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd. Accessed on September 5, 2006.
5. Centers for Medicare and Medicaid Services. National Coverage Determination for Treatment of Actinic Keratosis (AKs).  NCD #250.4. Effective November 26, 2001. Available at:  http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd. Accessed on September 5, 2006.
6. Coleman WP, Glogau RG, Klein JA, Moy RL, Narins RS, Chuang TY, Farmer ER, Lewis CW, Lowery BJ; American Acacemy of Dermatology Guidelines/Outcomes Committee.  Guidelines of care for liposuction. J Am Acad Dermatol. 2001 Sep;45(3):438-47. American Academy of Dermatology Association. Guidelines of care for liposuction. Available at:    http://www.aadassociation.org/Guidelines/liposuction.html Accessed on September 5, 2006.
7. Drake LA, Ceilley RI, Cornelison RL, et al.  Guidelines of care for actinic keratoses. Committee on Guidelines of Care.J Am Acad Dermatol. 1995 Jan;32(1):95-8. 
8. Guidelines of care for dermabrasion. American Academy of Dermatology Committee on Guidelines of Care.J Am Acad Dermatol. 1994 Oct;31(4):654-7. American Academy of Dermatology Association. Guidelines of care for dermabrasion.    http://www.aadassociation.org/Guidelines/dermabrasion.html Accessed on November 09, 2005.
9. Hayes Inc. Hayes Medical Technology Directory. Pulsed Dye Laser Therapy for Cutaneous Vascular Lesions. Lansdale, PA:  Hayes, Inc.; January 26, 2006. 
10. Sculptra™ [Product Insert] August 2004.  http://www.fda.gov/ohrms/dockets/dailys/04/aug04/ 081004/04m-0350-aav0001-04-Labeling-vol1.pdf. Accessed on September 5, 2006.

Web Sites for Additional Information

1. American Academy of Dermatology Association. Available at:  http://www.aad.org.  Accessed on September 5, 2006.
2. American Academy of Facial Plastic and Reconstructive Surgery. Available at:  http://www.aafprs.org/ Accessed on September 5, 2006.
3. American Academy of Plastic Surgery. Available at:  http://www.plasticsurgery.org Accessed on September 5, 2006.
4. American Society for Aesthetic Plastic Surgery. Available at:  http://surgery.org Accessed on September 5, 2006.

Index

The use of specific product names is illustrative only.  It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Policy History

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

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