Coverage Guideline

This document describes the cosmetic, reconstructive, and medically necessary uses of a selection of procedures addressing the treatment of abnormalities of the head and neck.

Note: Please see the following documents for additional information:

• ANC.00007 Cosmetic and Reconstructive Services: Skin Related
• ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities
• CG-OR-PR-04 Cranial Remodeling Bands and Helmets (Cranial Orthotics)
• CG-MED-96 Prefabricated External Infant Ear Molding Systems
• CG-SURG-03 Blepharoplasty, Blepharoptosis Repair, and Brow Lift
• SURG.00096 Surgical and Ablative Treatments for Chronic Headaches

Note: This document does not address gender affirming surgery or procedures. Criteria for gender affirming surgery or procedures are found in applicable guidelines used by the plan.

Note:  

• This document does not address septoplasty alone. Please refer to CG-SURG-18 Septoplasty for additional information.
• This document does not address surgical procedures involving the mandible, maxilla (or both) or genioplasty procedures. Please refer to CG-SURG-84 Mandibular/Maxillary (Orthognathic) Surgery for additional information.

Note: The use of botulinum toxin is not addressed in this document.

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant functional impairment AND the procedure can be reasonably expected to improve the functional impairment.

Reconstructive: In this document, 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.

NOTE: Not all benefit contracts/certificates include benefits for reconstructive services as defined by this document. Benefit language supersedes this document.

Cosmetic: In this document, 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 that are primarily intended to preserve or improve appearance.

A.        Facial Plastic Surgery:

Facial plastic surgery is considered medically necessary when required to correct a significant functional impairment and the procedure can be reasonably expected to improve the functional impairment. Examples include, but are not limited to, reconstructive procedures which correct or improve a significant functional impairment of speech, nutrition, control of secretions, protection of the airway, or corneal protection.

Facial plastic surgery is considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, or treatment of a disease or congenital defect.
Note: The initial restoration may be completed in stages.

Facial plastic surgery is considered cosmetic and not medically necessary when intended to change a physical appearance that would be considered within normal human anatomic variation.

Facial plastic surgery is considered cosmetic and not medically necessary when the medically necessary or reconstructive criteria in this section are not met.

B.        Otoplasty

Otoplasty is considered medically necessary when performed to surgically correct a physical structure or absence of a physical structure that is causing hearing loss, or intended to facilitate the use of a hearing aid or device when both of the following criteria are met:

1. the procedure is reasonably expected to improve the functional impairment; and
2. an audiogram documents a loss of at least 15 decibels in the affected ear(s).

Otoplasty is considered reconstructive when intended to restore a significantly abnormal external ear or auditory canal related to accidental injury, disease, trauma, or treatment of a disease or congenital defect.

Otoplasty is considered reconstructive when intended to restore the absence of the external ear due to accidental injury, disease, trauma, or the treatment of a disease or congenital defect.

Otoplasty is considered cosmetic and not medically necessary when intended to change a physical appearance that would be considered within normal human anatomic variation. Examples include, but are not limited to, repair of ear lobes with clefts or other consequences of ear piercing, or protruding ears.

Otoplasty is considered cosmetic and not medically necessary when the medically necessary or reconstructive criteria in this section are not met.

Otoplasty using a custom-fabricated device, including but not limited to a custom fabricated alloplastic implant, is considered cosmetic and not medically necessary.

C.        Rhinophyma

Excision or shaving of the rhinophyma is considered medically necessary when both of the following criteria are met:

1. the medical record documentation includes evidence of bleeding or infection; and
2. the procedure can be reasonably expected to improve functional impairment as a result of bleeding or infection.

Excision or shaving of the rhinophyma is considered cosmetic and not medically necessary when the medically necessary criteria in this section are not met.

D.        Rhinoplasty or Rhinoseptoplasty (procedure which combines both rhinoplasty and septoplasty)

Rhinoplasty is considered medically necessary when both of the following criteria are met:

1. the medical record documentation includes evidence of the failure of conservative medical therapy for severe airway obstruction from deformities due to disease, structural abnormality, or previous therapeutic process that will not respond to septoplasty alone; and
2. the procedure can be reasonably expected to improve the functional impairment.

Note: Only the initial restorative repair is medically necessary, unless the procedure is completed in stages with healing periods, then all stages are medically necessary.

Note: Rhinoseptoplasty is considered medically necessary when the criteria above for rhinoplasty are met and medically necessary criteria in CG-SURG-18 Septoplasty are also met.

Rhinoplasty is considered reconstructive if there is documented evidence (that is, radiographs or appropriate imaging studies) of nasal fracture resulting in significant variation from normal without functional impairment. The intent of the surgery is to correct the deformity caused by the nasal fracture.

Rhinoseptoplasty is considered reconstructive if there is documented evidence (that is, radiographs or appropriate imaging studies) of nasal and septal fracture resulting in significant variation from normal without functional impairment. The intent of the surgery is to correct the deformity caused by the nasal and septal fracture.

Rhinoplasty or rhinoseptoplasty to modify the shape or size of the nose is considered cosmetic and not medically necessary when the medically necessary or reconstructive criteria in this section are not met.

E.         Rhytidectomy (Face lift)

Rhytidectomy is considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect. Examples include, but are not limited to, significant burns or other significant major facial trauma.

Rhytidectomy is considered cosmetic and not medically necessary when the reconstructive criteria in this section are not met, including, but not limited to, removal of wrinkles, excess skin, or to tighten facial muscles.

F.         Cranial Nerve Procedures  

Transfers, anastomosis or other procedures of the facial nerve or other cranial nerves or their branches are considered medically necessary to correct a significant functional impairment and the procedure can be reasonably expected to improve the functional impairment. Examples of cranial nerve procedures to correct a functional impairment include, but are not limited to, procedures to allow for speech, nutrition, control of secretions, protection of the airway, or corneal protection.

Transfers, anastomosis or other procedures of the facial nerve or other cranial nerves or their branches 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. Examples of significant variation from normal include, but are not limited to, congenital or acquired facial palsy.

Transfers, anastomosis or other procedures of the facial nerve or other cranial nerves or their branches are considered not medically necessary when the medically necessary or reconstructive criteria in this section are not met.

G.        Ear or Body Piercing

Ear or body piercing is considered cosmetic and not medically necessary when performed for any reason.

H.        Frown Lines

Removal of frown lines is considered cosmetic and not medically necessary when performed for any reason, including, but not limited to, the excision or correction of glabella frown lines or forehead lift (cosmetic foreheadplasty).

I.          Neck Tuck (Submental Lipectomy)

Neck tucks are considered cosmetic and not medically necessary when performed for any reason.

Concepts of Medical Necessity, Reconstructive and Cosmetic

The coverage eligibility of medical and surgical therapies to treat head and neck 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 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 person 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 definitions, 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.

Facial plastic surgery is a general term for any surgery performed for the purpose of altering the appearance of the face. Facial plastic surgery may be considered cosmetic or may be considered medically necessary in those instances where severe abnormalities result in functional impairments that affect speech, nutrition, control of secretions, protection of the airway, or corneal protection. Reconstructive surgery to the midface, orbital rims or the forehead may require augmentation or reduction, osteotomy, bone or cartilage grafting, or a combination of these procedures. These procedures may also be reasonable to correct or restore appearance following traumatic injuries or a previous surgery done to treat a medical or surgical condition that resulted in anatomical changes. Other procedures are not done to correct a functional impairment. Surgery for frown lines is intended to remove wrinkles that result from the aging process. A “neck tuck”, also known as a neck lift, lower rhytidectomy or submental lipectomy, is a surgical procedure to remove excess skin and fat from the neck area under the chin. This area may also be referred to as a double chin. These surgeries are not reconstructive in nature but are performed for cosmetic purposes.

Osteotomy and osteoplasty are surgical procedures which involve the opening of a bone (osteotomy), or the reconfiguration of a bone (osteoplasty). Such procedures are required when the alignment of a bony structure is misaligned to such a degree that it results in functional impairment. These surgeries are usually complex and may involve several procedures or stages to accomplish the desired result.

Otoplasty refers to surgical procedures intended to reshape the structure of a misshapen or injured outer ear, or to construct an ear that is incompletely formed (microtia), small, or absent (anotia) at birth, or has been deformed as a result of trauma. Atresia refers to a more severe condition in which the individual lacks an external auditory canal. Microtia and anotia may be found in congenital conditions affecting development of the first and second branchial arches, such as Goldenhar syndrome, hemifacial microsomia, and Treacher-Collins syndrome. They can also be associated with congenital malformations of the face, limbs, heart, or kidneys, or with maternal exposure to teratogens.

Otoplasty is considered reconstructive when it is intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect. When no reconstructive indication is present, otoplasty is considered cosmetic if there is no functional impairment.

The structural framework used to develop the reconstructed ear is made using costal cartilage or an alternative device, commonly a biocompatible porous polyethylene implant. Costal reconstruction is a four-stage procedure using a second surgical site, typically a rib, to harvest autologous material. While costal reconstruction is more complex and invasive, it is considered more durable, with a lower infection rate and a good cosmetic result. Alloplastic devices are less invasive and can be used in situations where costal harvesting cannot be performed, but they are associated with a higher rate of extrusion and infection (Siegert, 2019). For both techniques, a template is created based on radiographs of the normal ear, or of a family member’s ear in the case of bilateral microtia. A prefabricated device is typically comprised of 2 pieces, which are then trimmed and custom fitted to size using the template and assembled using sutures or welds (Constantine, 2014). Alternatively, custom fabricated implants are typically a 1-piece implant created using 3D imaging.

Rhinophyma is a condition where the nose becomes enlarged, red in color, and bulbous. The cause of rhinophyma is unknown but has been associated with rosacea, a chronic skin rash that is characterized by reddening of the skin on the face. Because this condition results in numerous pits and fissures in the skin, bleeding and infection may develop indicating the need for further medical treatment. In all other circumstances, treatment of rhinophyma is considered cosmetic in nature.

Rhinoplasty, septoplasty, and rhinoseptoplasty (or septorhinoplasty) are procedures that involve distinct surgical techniques. When rhinoplasty is performed to alter the shape (contour) or enhance the external appearance of the nose (that is, a “nose job”), the procedure has no medical benefit and is considered cosmetic and not medically necessary. Rhinoplasty may be performed to alter the shape of the nose to improve the passage of air while breathing (from blocked nasal passages or severe nasal obstruction), or to correct structural damage due to disease or trauma (for example, to repair a nasal fracture) without involvement of the underlying nasal septa. Rhinoplasty is medically indicated when these conditions exist. Septoplasty, usually performed under local or general anesthesia, is a surgical procedure to correct nasal septum defects or deformities by alteration, splinting, or partial removal of obstructing structures (Note: The indications for septoplasty alone are not addressed in this document). Septoplasty is an internal procedure which does not affect the outward appearance of the nose, is usually performed to improve breathing, but may also be performed to assist in the management of polyps, tumors or epistaxis. Rhinoseptoplasty, involving both rhinoplasty and septoplasty, is a more extensive surgical procedure combining repairs to the external nasal pyramid or skeleton with repairs of the nasal septa to correct a functional impairment involving both structures. Rhinoseptoplasty may also be performed as a reconstructive procedure to correct a nasal and septal fracture resulting in significant variation from normal without functional impairment. The intent of the surgery is to correct the deformity caused by the nasal and septal fracture.

A rhytidectomy or “face lift” is a surgical procedure where excess skin is removed from the face and the facial muscles are tightened. This procedure may correct a facial abnormality due to burns or facial palsy resulting in a droopy appearance. In addition, face lifts are used to create a more youthful appearance in individuals concerned with changes due to the aging process. In individuals with facial injuries due to burns or lax facial muscles due to palsy, the use of rhytidectomy may allow the restoration of a normal appearance. Rhytidectomy is considered a cosmetic procedure for individuals with no functional impairment, disease, or injury-related facial changes.

Nerve anastomosis or grafting, decompression, and peripheral neuroplasty are examples of surgical procedures performed to correct functional impairment that may result from cranial and facial nerve pathology, injury or dysfunction. These procedures are expected to improve the individual’s functions involving speech, nutrition, control of secretions, corneal protection, or airway protection. These reconstructive surgical procedures are also performed to address an individual’s significantly altered appearance in the treatment of congenital or acquired facial palsy.

Ear and body piercing is done for cosmetic or aesthetic reasons. Piercing the ears, nose, lip, or any other body part has no acceptable medical use and therefore is not considered medically necessary.

Osteotomy/Osteoplasty: A surgical procedure that involves the opening of a bone (osteotomy), or to reconfigure a bone (osteoplasty).

Otoplasty: A surgical procedure to reshape or rebuild the ear.

Palsy: A condition affecting the nerves that results in the inability of voluntary movement (motor function) or paralysis, generally partial, of a body area.

Rhinophyma: A condition of the face consisting of a bulbous, enlarged, red nose and puffy cheeks. There may also be thick bumps on the lower half of the nose and the nearby cheek areas.

Rhinoplasty: A surgical procedure intended to reshape the nose or repair a broken nose.

Rhinoseptoplasty: A surgical procedure, also referred to as a septorhinoplasty, performed on the nose and the nasal septum (cartilage and bony structure that separates the two nostrils).

Rhytidectomy: A surgical procedure intended to adjust the appearance of the face by removing excess skin and tightening the underlying muscles.

Septoplasty: A surgical procedure intended to repair the nasal septum.

Submental lipectomy: A surgical procedure, also referred to as a neck tuck, intended to remove excess fat and skin (“double chin”) from the neck below the chin.

The following codes for treatments and procedures applicable to this document 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.

A. Facial Plastic Surgery
When services may be Medically Necessary or Reconstructive when criteria are met:

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above, when criteria are not met for medically necessary or reconstructive services, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

B. Otoplasty
When services may be Medically Necessary or Reconstructive when criteria are met

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above, when criteria are not met for medically necessary or reconstructive services, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary, including the following

C. Rhinophyma Surgery
When services may be Medically Necessary when criteria are met:

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above when criteria are not met for medically necessary services, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

D. Rhinoplasty or Rhinoseptoplasty
When services may be Medically Necessary or Reconstructive when criteria are met:

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above when criteria are not met for medically necessary or reconstructive services, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

E. Rhytidectomy (face lift)
When services may be Reconstructive when criteria are met:

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above when criteria are not met for medically necessary or reconstructive services, or when the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

F. Cranial Nerve Procedures
When services may be Medically Necessary or Reconstructive when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met for medically necessary or reconstructive services, or when the code describes a procedure indicated in the Position Statement section as not medically necessary.

G. Other Procedures (Ear piercing, Frown lines, Neck Tuck)
When services are Cosmetic and Not Medically Necessary:

Peer Reviewed Publications:

1. Bagheri SC, Meyer RA, Khan HA, Steed MB. Microsurgical repair of peripheral trigeminal nerve injuries from maxillofacial trauma. J Oral Maxillofac Surg. 2009; 67(9):1791-1799.
2. Ballon A, Landes CA, Zeilhofer HF, et al. The importance of the primary reconstruction of the traumatized anterior maxillary sinus wall. J Craniofac Surg. 2008; 19(2):505-509.
3. Becker DG, Becker SS. Reducing complications in rhinoplasty. Otolaryngol Clin North Am. 2006; 39(3):475-492, viii.
4. Boccieri A, Macro C. Septal considerations in revision rhinoplasty. Facial Plast Surg Clin North Am. 2006; 14(4):357-371, vii.
5. Cakmak O, Buyuklu F. Crushed cartilage grafts for concealing irregularities in rhinoplasty. Arch Facial Plast Surg. 2007; 9(5):352-357.
6. Charalampaki P, Kafadar AM, Grunert P, et al. Vascular decompression of trigeminal and facial nerves in the posterior fossa under endoscope-assisted keyhole conditions. Skull Base. 2008; 18(2):117-128.
7. Constantine KK, Gilmore J, Lee K, Leach J Jr. Comparison of microtia reconstruction outcomes using rib cartilage vs porous polyethylene implant. JAMA Facial Plast Surg. 2014; 16(4):240-244.
8. Corey CL, Most SP. Treatment of nasal obstruction in the posttraumatic nose. Otolaryngol Clin North Am. 2009; 42(3):567-578.
9. Ducic Y. Reconstruction of the scalp. Facial Plast Surg Clin North Am. 2009; 17(2):177-187.
10. Funamura JL, Tollefson TT. Congenital Anomalies of the Nose. Facial Plast Surg. 2016; 32(2):133-1341.
11. Higuera S, Lee EI, Cole P, et al. Nasal trauma and the deviated nose. Plast Reconstr Surg. 2007; 120(7 Suppl 2):64S-75S.
12. Howard BK, Rohrich RJ. Understanding the nasal airway: principles and practice. Plast Reconstr Surg. 2002; 109(3):1128-1134.
13. Kim JH, Lee JW, Park CH. Cosmetic rhinoseptoplasty in acute nasal bone fracture. Otolaryngol Head Neck Surg. 2013; 149(2):212-218.
14. Lee J, White WM, Constantinides M. Surgical and nonsurgical treatments of the nasal valves. Otolaryngol Clin North Am. 2009; 42(3):495-511.
15. Lewin S. Complications after total porous implant ear reconstruction and their management. Facial Plast Surg. 2015; 31(6):617-625.
16. Mehta RP. Surgical treatment of facial paralysis. Clin Exp Otorhinolaryngol. 2009; 2(1):1-5.
17. Miller LE, Miller VM. Safety and effectiveness of microvascular decompression for treatment of hemifacial spasm: a systematic review. Br J Neurosurg. 2012; 26(4):438-444.
18. Moolenburgh SE, McLennan L, Levendag PC, et al. Nasal reconstruction after malignant tumor resection: an algorithm for treatment. Plast Reconstr Surg. 2010; 126(1):97-105.
19. Moore M, Eccles R. Objective evidence for the efficacy of surgical management of the deviated septum as a treatment for chronic nasal obstruction: a systematic review. Clin Otolaryngol. 2011; 36(2):106-113.
20. Pluijmers BI, Caron CJ, Dunaway DJ, et al. Mandibular reconstruction in the growing patient with unilateral craniofacial microsomia: a systematic review. Int J Oral Maxillofac Surg. 2014; 43(3):286-295.
21. Rhee JS, Arganbright JM, McMullin BT, Hannley M. Evidence supporting functional rhinoplasty or nasal valve repairs: a 25-year systematic review. Otolaryngol Head Neck Surg. 2008; 139(1):10-20.
22. Rhee JS, Weaver EM, Park SS, et al. Clinical consensus statement: diagnosis and management of nasal valve compromise. Otolaryngol Head Neck Surg. 2010; 143(1):48-59.
23. Ribeiro JS, da Silva GS. Technical advances in the correction of septal perforation associated with closed rhinoplasty. Arch Facial Plast Surg. 2007; 9(5):321-327.
24. Saltaji H, Altalibi M, Major MP, et al. Le Fort III distraction osteogenesis versus conventional Le Fort III osteotomy in correction of syndromic midfacial hypoplasia: a systematic review. J Oral Maxillofac Surg. 2014; 72(5):959-972.
25. Serowka KL, Saedi N, Dover JS, Zachary CB. Fractionated ablative carbon dioxide laser for the treatment of rhinophyma. Lasers Surg Med. 2014; 46(1):8-12.
26. Siegert R, Magritz R. Otoplasty and auricular reconstruction. Facial Plast Surg. 2019; 35(4):377-386.
27. Stucker FJ, Lian T, Sanders K. Management of severe bilateral nasal wall collapse. Am J Rhinol. 2002; 16(5):243-248.
28. Vuyk HD. A review of practical guidelines for the correction of deviated, asymmetric nose. Rhinology. 2000; 38(2):72-78.
29. Yetiser S, Karapinar U. Hypoglossal-facial nerve anastomosis: a meta-analytic study. Ann Otol Rhinol Laryngol. 2007; 116(7):542-549.
30. Yugueros P, Friedland JA. Otoplasty: the experience of 100 consecutive patients. Plast Reconstr Surg. 2001; 108(4):1045-1053.
31. Zhang YX, Wang D, Follmar KE, et al. A treatment strategy for postburn neck reconstruction: emphasizing the functional and aesthetic importance of the cervicomental angle. Ann Plast Surg. 2010; 65(6):528-534.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations. Plastic Surgery to Correct Moon Face. NCD #140.4. Effective May 1, 1989. Available at: https://www.cms.gov/medicare-coverage-database/search.aspx. Accessed on January 29, 2024.
2. U.S. Food and Drug Administration (FDA) 510(k) Premarket Notification Database. Summary of Safety and Effectiveness. Rockville, MD: FD Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMA/pma.cfm. Accessed on January 29, 2024:
   • Stryker CMF MEDPOR Customized Implant. No. K143173. March 23, 2015.
   • Su-Por^® Surgical Implant. No. K140437. June 13, 2014.
   • Su-Por Patient-Specific Surgical Implant. No. K152463. January 20, 2016.

1. American Academy of Otolaryngology-Head and Neck Surgeons (AAO-HNS). Available at: http://www.entnet.org/. Accessed on January 29, 2024.
2. American Academy of Facial Plastic and Reconstructive Surgery, Inc. (AAFPRS). Available at: http://www.aafprs.org/. Accessed on January 29, 2024.
3. U.S. National Library of Medicine Medline Plus. Head and face reconstruction. Available at: https://www.nlm.nih.gov/medlineplus/ency/article/002980.htm. Accessed on January 29, 2024.

Crouzon Syndrome
Goldenhar Syndrome
Lower Rhytidectomy
Neck Lift
Parry-Romberg Syndrome
Platysmaplasty
Rhytidectomy
Treacher-Collins Syndrome

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.

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Coverage Guidelines 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. Coverage Guidelines, 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 Coverage Guidelines 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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