Reconstructive Surgery

Reconstructive surgery is surgery performed to restore normal appearance and function to body parts malformed by a disease or medical condition.

Description

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. The surgeon may not be using the Medicare or reimbursement criteria when referring to a procedure as reconstructive or cosmetic. Plastic surgeons,