Common use of Surgery Services Clause in Contracts

Surgery Services. Abdominoplasty*. • Brow ptosis surgery*, unless medically necessary as indicated in our medical policies. • Cervicoplasty. • Chemical exfoliations, peels, abrasions, dermabrasions, or planing for acne, scarring, wrinkling, sun damage or other benign conditions. • Correction of variations in normal anatomy including augmentation mammoplasty, mastopexy, and correction of congenital breast asymmetry*. • Dermabrasion. • Ear piercing or repair of a torn earlobe. • Excision of excess skin or subcutaneous tissue except for panniculectomy. • Genioplasty*. • Hair transplants. • Hair removal including electrolysis epilation, unless in relation to gender affirming services or skin grafting. • Inverted nipple surgery. • Laser treatment for acne and acne scars. • Osteoplasty - facial bone reduction*. • Otoplasty. • Procedures to correct visual acuity including but not limited to cornea surgery or lens implants. • Removal of asymptomatic benign skin lesions. • Repeated cauterizations or electrofulguration methods used to remove growths on the skin. • Rhinoplasty*. • Rhytidectomy*. • Scar revision, regardless of symptoms. • Sclerotherapy for spider veins. • Skin tag removal. • Subcutaneous injection of filling material*. • Suction assisted Lipectomy*, unless medically necessary as indicated in our medical policies. • Tattooing or tattoo removal except tattooing of the nipple/areola related to a mastectomy. • Treatment of vitiligo. • Standby services of an assistant surgeon or anesthesiologist. • Orthodontic services related to orthognathic surgery. • Cosmetic procedures when performed primarily*: o to refine or reshape body structures or dental structures that are not functionally impaired; o to improve appearance or self-esteem; or o for other psychological, psychiatric or emotional reasons. • Drugs, biological products, hospital charges, pathology, radiology fees and charges for surgeons, assistant surgeons, attending physicians and any other incidental services, which are related to cosmetic surgery. * Services marked with an asterisk may be covered when provided in relation to gender affirming services. See Gender Affirming Services in Section 3 for details.