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Contractor Information

Contractor Name: Palmetto GBA - Full list of policies of this Medicare Contractor Contractor Number: 11502 Contractor Type: MAC B

LCD Information

LCD ID Number: L33428 Status: A-Approved LCD Title: Cosmetic and Reconstructive Surgery Geographic Jurisdiction: North Carolina Other Jurisdictions Original Determination Effective Date: 10/01/2015 Original Determination Ending Date: Revision Effective Date: 07/29/2021 Revision End Date: CMS National Coverage Policy: Title XVIII of the Social Security Act §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Title XVIII of the Social Security Act §1862(a)(10) indicates where such expenses are for cosmetic surgery or are incurred in connection therewith, except as required for the prompt repair of accidental injury or for improvement of the functioning of a malformed body member. Title XVIII of the Social Security Act, §1862(a)(1)(D) addresses items and services related to research and experimentation. CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §150 Dental Services and §150.1 Treatment of Temporomandibular Joint (TMJ) Syndrome CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §140.2 Breast Reconstruction Following Mastectomy and §140.4 Plastic Surgery to Correct "Moon Face" CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §250.5 Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS) Sorry, you need to login or register to view additional sections of this Medicare policy. *