Coverage should include treatment which, in the opinion of the treating physician, is medically necessary to return the patient to a more normal appearance, even if the procedure does not materially affect the function of the body part being treated, including benefits for conditions and follow-up treatment.
Definitions
Covered treatment should include reconstructive surgery which is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.2
Covered treatment should not include cosmetic surgery, defined by the American Medical Association as surgery performed to reshape normal structures of the body to improve the patient's appearance and self-esteem.3
In defining what is a medical necessity, the American Academy of Pediatrics has recognized children often require comprehensive services to promote physical, intellectual, and emotional development. Disruption of developmental patterns during childhood may result in delayed long-term effects that can present during later adulthood.4
The American Society of Plastic Surgeons has developed Clinical Practice Guidelines to assist physicians in clinical decision making. The Guidelines are strategies for patient management. They are based on a thorough evaluation of scientific literature and clinical experience and describe a range of generally acceptable approaches to diagnose, manage, or prevent specific diseases or conditions.
To date, ASPS has Clinical Practice Guidelines on the following procedures related to children's deformities: nasal deformity; ear deformity: prominent ears; gynecomastia; cleft lip and palate; craniosynostosis; maxillofacial trauma; temporal mandibular joint disorders; maxillofacial/orthognathic procedures; and cranial base surgery.
Scope
Of the total 1.9 million operative procedures performed annually on adults and children by plastic surgeons in 1996, 1.2 million were reconstructive procedures.5 Conditions for which reconstructive surgery was performed are described as animal bites, birth defects (congenital anomalies), burn care, hand surgery, breast reconstruction following mastectomy, lacerations, maxillofacial surgery, microsurgery, scar revision, and tumor removal. Congenital anomalies (birth defects) represents approximately 29,200 procedures or 1.5% of the total.6 Examples of congenital anomalies include, but are not limited to, cleft lip and palate, congenital skin lesions, malformations of the ear (microtia and prominent ears), and craniofacial deformities.
Covered care should not include cosmetic surgery. According to the ASPS 1996 Plastic Surgery Statistics, these procedures are described as cosmetic breast augmentation, cosmetic breast lift (mastopexy), buttock lift, cosmetic cheek implants, chemical peel, cosmetic chin augmentation, collagen injections, dermabrasion, cosmetic ear surgery (cosmetic forms of otoplasty), cosmetic eyelid surgery (cosmetic forms of belpharoplasty), facelift, fat injections, forehead lift (cosmetic foreheadplasty), laser skin resurfacing, liposuction, treatment of male-pattern baldness, cosmetic nose reshaping (cosmetic rhinoplasty), retin-A treatment for wrinkles, thigh lift, tummytuck (abdominoplasty), upper arm lift (cosmetic brachioplasty), and wrinkle injection (collagen injection).
Timing of Health Care Coverage
Hospital, health or medical expense insurance policies, and healthcare service contracts that provide medical or surgical benefits to an insured and his/her family member, should also provide coverage for benefits described above to a newly-born child of the insured from the moment of birth, and an adopted child effective upon placement for adoption.
Hospital, health, or medical expense insurance policies, and healthcare service contracts that provide medical or surgical benefits to an insured and his/her family member, should not deny coverage for benefits described above as a pre-existing condition, or other inappropriate medical underwriting practices, if the insured's insurance coverage changes before treatment is either initiated or completed.7
Background
American Society of Plastic Surgeons
The American Society of Plastic Surgeons (ASPS) is the largest organization of plastic surgeons in the world. Requirements for membership include certification by the American Board of Plastic Surgery as recognized by the American Board of Medical Specialties.
ASPS represents 97 percent of the board-certified plastic surgeons practicing in the United States and Canada. It serves as the primary educational resource for plastic surgeons and as their voice on socioeconomic issues. ASPS is recognized by the American Medical Association (AMA), the American College of Surgeons (ACS) and other organizations of specialty societies.
American Academy of Pediatrics
The American Academy of Pediatrics is an organization of 53,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists dedicated to the health, safety and well-being of infants, children, adolescents, and young adults.
References
- Committee on Child Health Financing, American Academy of Pediatrics. "Scope of Health Care Benefits for Newborns, Infants, Children, Adolescents, and Young Adults Through The Age 21 Years." Pediatrics. 100:1040, 1997.
- American Medical Association, House of Delegates. AMA Policy Compendium. Chicago, IL, H-475.992:616, 1989.
- Ibid.
- Berman, Steve. "A Pediatric Perspective on Medical Necessity." Arch. Pediatr. Adolesc. Med. 151:858, 1997.
- American Society of Plastic Surgeons. 1996 Plastic Surgery Statistics. Arlington Heights, IL, 1996.
- Ibid.
- Committee on Child Health Financing, American Academy of Pediatrics. "Principles of Child Health Care Financing." Pediatrics. 91:506, 1993.
Endorsed by the American Academy of Pediatrics
