Otoplasty Policy Number: PG0376 ADVANTAGE | ELITE | HMO Last Review: 09/13/2016

INDIVIDUAL MARKETPLACE | PROMEDICA MEDICARE PLAN | PPO GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement.

SCOPE X Professional _ Facility

DESCRIPTION is a surgical procedure to approximate normal anatomic shape and appearance of the pinna or external . The external ear is comprised of the auricle (helix, antihelix, inferior crus, superior crus, concha), auditory canal (external acoustic meatus), earlobe and the outer layer of the eardrum (tympanic membrane).

Cosmetic services are defined as services which are used to improve a person's appearance, but not their functionality. Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem. Their condition is not impairing their ability to participate in daily activities and routines.

Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.

POLICY Otoplasty (69300) requires prior authorization for all product lines.

COVERAGE CRITERIA HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan, Advantage Reconstructive procedures are considered eligible for coverage. Otoplasty is considered reconstructive when performed for correction of deformities/ defects due to:  Trauma; OR  Disease (eg, infection, perichondritis, tumor); OR  Congenital malformation (eg, aural atresia, aural stenosis, microtia) that results in severe loss as demonstrated by an audiogram that indicates a loss of at least 15 in the affected ear(s).

Cosmetic procedures are not considered eligible for coverage. Otoplasty is considered cosmetic when performed solely to improve physical appearance.

Paramount does not cover otoplasty for any indication, including the following, because it is considered cosmetic in nature and not medically necessary (this list may not be all-inclusive):  prominent/protruding  lop ears  cupped ears  constricted ears

PG0376 – 12/22/2020

CODING/BILLING INFORMATION The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered. CPT CODE 69300 Otoplasty, protruding ear, with or without size reduction

REVISION HISTORY EXPLANATION ORIGINAL EFFECTIVE DATE: 09/13/2016 09/13/16: Policy created to reflect most current clinical evidence per Medical Policy Steering Committee. 12/22/2020: Medical policy placed on the new Paramount Medical Policy Format

REFERENCES/RESOURCES Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Ohio Department of Medicaid American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets Industry Standard Review Hayes, Inc.

PG0376 – 12/22/2020