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Concept
Reconstructive surgery
Résumé
Reconstructive surgery is surgery performed to restore normal appearance and function to body parts malformed by a disease or medical condition.
Reconstructive surgery is a term with training, clinical, and reimbursement implications. It has historically been referred to as synonymous with plastic surgery. In regard to training, Plastic Surgery is a recognized medical specialty and a surgeon can be a "board-certified" plastic surgeon by the American Board of Plastic Surgery. However, reconstructive surgery is not a specialty and there are no board-certified reconstructive surgeons.
More accurately, reconstructive surgery should be contrasted with cosmetic surgery. Reconstructive surgery is performed to
Improve/restore to normal function.
Restore to a normal appearance of "abnormal" or "malformed" body parts caused by the disease or condition and/or
Improve the patient's quality of life.
Separately, the patient must be healthy enough so that the benefits of the procedure outweigh the risks of complications or death. A procedure could be considered reconstructive but not medically necessary due to the risk to the patient.
In addition Section 1862(a) (1) (A) of the Social Security Act directs the following:
"No payment may be made under Part A or Part B for any expenses incurred for items or services not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member." Therefore, outside clinical interpretation and carrier guidelines, there is a federal statute that "improving functionality and restoring appearance" are covered as reconstructive and medically necessary.
This definition is contrasted with cosmetic surgery performed to improve aesthetics or the appearance of a body part. A plastic surgeon can perform both reconstructive and cosmetic procedures. Some procedures, such as a panniculectomy (aka tummy tuck) can be considered as cosmetic by one insurance company and reconstructive by another.
Source officielle
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