Cosmetic Surgery and Procedures
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Defines Aetna's coverage stance for cosmetic surgery and procedures, specifying which procedures may be medically necessary and which are considered cosmetic or investigational; applies to Aetna plans and providers seeking coverage determinations.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medically necessary procedures with CPB-based criteria
Covered when ALL of the following are met
Supported by policy introduction
See individual CPB references in document
Cosmetic Exclusion (General)
Not covered when cosmetic:
Policy background: cosmetic surgery exclusion
Injectables and device-based treatments
Covered when FDA-approved for specific indications and used for those indications:
Coverage contingent on indication and any additional policy criteria or prior authorization requirements
Liposuction for lipedema — indication criteria
Surgical treatment (e.g., liposuction) for lipedema is considered when ALL of the following are met:
Derived from guideline summaries and recommendations; tumescent liposuction is the surgical technique of choice when criteria met
The policy enumerates a wide range of procedures that Aetna considers cosmetic and therefore excluded from coverage. Examples listed include: aesthetic alteration of the female genitalia (e.g., hymenoplasty, labiaplasty), aesthetic operations on the umbilicus, breast augmentation and mastopexy (breast lift), buttock lift/augmentation, cheek and chin implants, correction of diastasis recti, correction of inverted nipple, hair transplant for age-related thinning, testicular prostheses except when replacing congenitally absent or lost testes for medical reasons, ear/body piercing, electrolysis/laser hair removal (except as specified for gender dysphoria), thigh/arm/submental/other regional excisions (thighplasty, arm lift, etc.), eyebrow/eyelash tattooing, mesotherapy, neck tucks, tattoo removal, and treatment with small or large gel-particle hyaluronic acid fillers for cosmetic contouring. This list is illustrative of the many procedures in the policy characterized as cosmetic and subject to exclusion unless a narrow exception applies (for example, prompt repair after accidental injury or reconstruction of a malformed body member that provides functional benefit).
Aetna’s policy states that procedures performed primarily to improve appearance are excluded as cosmetic; the underlying condition that produces the preoperative appearance is generally not a basis for coverage. The policy further identifies specific CPT/ICD-10 entries and diagnostic conditions that may be treated as exclusion triggers when used to justify cosmetic procedures, including diagnoses such as F45.22 (body dysmorphic disorder), F52.0–F52.9 / F64.0–F66 (sexual and gender identity disorders), and L68.0–L68.9 (hirsutism). Providers should note these codes when submitting claims and understand that claims driven by cosmetic indications may be denied unless they meet the narrow exceptions described in the policy.
The document specifies that Qwo (collagenase clostridium histolyticum-aaes) must not be substituted for other injectable collagenase products. It also clarifies that Qwo is not indicated for the treatment of Peyronie’s disease or Dupuytren’s contracture; those conditions are addressed under separate CPBs referenced in the policy.
Within the provided excerpts there are citations and case reports describing complications after eyebrow and eyelash tattooing (e.g., epithelioid granulomatous inflammation, peri-orbital pigmentation), but the policy text in these chunks does not state any explicit coverage exclusions or specific medical necessity criteria unique to eyebrow or eyelash tattooing. The document records reported adverse events and pathology findings without defining separate coverage rules for these procedures in the quoted sections.
The policy explicitly lists numerous procedures as cosmetic and not medically necessary. Items called out include aesthetic genital procedures (labiaplasty, hymenoplasty, mons pexy), umbilical aesthetic operations, breast augmentation and mastopexy, buttock augmentation/lifts, facial implants (cheek, chin), mesotherapy, neck tucks, removal of frown lines/spider angioma, correction of moon face or tuberous breast deformity, tattoo removal, and tattooing/eyebrow or eyelash tattooing among others. Also noted are treatments with small and large gel-particle hyaluronic acid fillers for contouring and reducing depressions due to acne, injury, scars, or wrinkles when no functional impairment exists; these are considered cosmetic and not medically necessary.
The policy describes that use of hyaluronic acid gel products (for example, Restylane, Perlane) to improve skin contour or reduce depressions from acne, injury, scars, or wrinkles is considered cosmetic because such contour irregularities are not deemed functional impairments. Systematic reviews cited in the policy document note evidence of safety and efficacy in certain facial areas, but the policy’s coverage determination treats these aesthetic indications as not medically necessary in the absence of functional deficit.
The policy frames Qwo’s role narrowly: it recognizes Qwo as an FDA-approved collagenase formulation for cellulite but explicitly states that use of Qwo outside its approved cosmetic indication (for example, for Peyronie’s disease or Dupuytren’s contracture) is not appropriate. Thus, off-label uses are not supported by the language in these excerpts and Qwo should not be considered interchangeable with other collagenase products for non‑indicated conditions.
The portions of the policy excerpt addressing eyebrow and eyelash tattooing summarize case reports of complications (granulomatous inflammation, peri-orbital pigmentation) and note that such procedures are commonly performed with a low reported complication rate. However, in these chunks the document does not set out specific not-medically-necessary (NMN) conditions or a separate NMN list tied specifically to tattooing or related cosmetic pigmenting procedures.
Coding
Provider Actions & Authorization
Prior Authorization for Selected CPTs and Injectables
Prior authorization may be required for selected procedures and injectable/device administrations. Certain CPT and HCPCS codes listed in the policy (for example, injectable products and select procedural codes) are subject to prior review and require documentation that medical necessity criteria are met prior to payment.
- Affected code sets include select CPT and HCPCS codes in the Applicable Codes sections (see policy code lists).
- Prior authorization is routinely requested for injectable products such as daxibotulinumtoxinA (Daxxify), deoxycholic acid (J0591; Kybella), collagenase (J0775/Qwo), and other HCPCS Q-codes (e.g., Q2026, Q2028).
Prior Authorization for Deoxycholic Acid (Kybella) Off‑Label Uses
Requests for off‑label use of deoxycholic acid (Kybella) for body areas other than persistent submental fat should include the FDA‑approved indication and supporting clinical evidence demonstrating medical necessity for the off‑label region. Coverage for off‑label DCA use is evaluated on a case‑by‑case basis and may require prior authorization.
- Document FDA‑approved indication (persistent submental fat) when applicable.
- For off‑label requests, provide literature, clinical rationale, and patient‑specific anatomic/clinical details to justify medical necessity.
Prior Authorization May Be Required for Specific Injectables/Devices
Some injectables and device products are specifically listed as not covered for the indications shown; others may require prior authorization depending on the plan. Check the Applicable CPT/HCPCS lists and submit prior authorization when indicated.
Denial Risk for Cosmetic / Non‑Medically Necessary Procedures
The policy reserves the right to deny coverage for procedures performed primarily for cosmetic purposes. Procedures intended to improve appearance without a documented medical necessity are excluded and may be denied.
- Cosmetic exclusion applies to surgical/procedural interventions directed at improving appearance.
- Exceptions exist when a procedure is medically necessary to improve function, treat disease, repair an injury, or correct a congenital defect — documentation must support the indication.
Cosmetic Exclusion / Denial Risk
Procedures directed at improving appearance are excluded as cosmetic unless criteria demonstrating medical necessity are met. Claims with cosmetic indications may be denied unless the request meets the stated medical‑necessity criteria and plan exceptions.
- Surgeries to correct the result of injury, post‑mastectomy reconstruction, and specified congenital defect repairs may be covered — verify against plan language.
- Providers should attach clinical records demonstrating functional impairment or disease‑directed need when submitting authorization requests.
Specific ICD‑10 Denial Triggers
Certain ICD‑10 diagnosis codes are identified as potential denial triggers when used for cosmetic indications. Use appropriate, disease‑specific ICD‑10 codes that substantiate medical necessity rather than cosmetic intent.
- ICD‑10 codes listed as not covered for cosmetic indications include F45.22 (body dysmorphic disorder), F52.0–F52.9, F64.0–F66 (sexual and gender identity disorders), and L68.0–L68.9 (hirsutism).
- Covered diagnosis examples (when criteria met) include B20, E88.1, L71.1, L91.0, and others listed in the Applicable Codes section.
Qwo Substitution / Indication Risk
Qwo (collagenase clostridum histolyticum‑aaes) must not be substituted for other collagenase products and is only indicated for cellulite in the buttocks; use for Peyronie’s disease or Dupuytren’s contracture is outside the indicated use and may lead to denial.
- Do not substitute Qwo for other collagenase formulations.
- Qwo is FDA‑approved for moderate to severe cellulite of the buttocks in adult women only; requests for other indications should cite appropriate coverage policies for those conditions.
Prior Authorization Not Specified / Not Applicable Content
Some items in the policy are informational only or have no specified prior authorization requirement in this section. When prior authorization is not specified, follow customary plan administrative rules and consult benefit documents.
- Eyebrow and eyelash tattooing have no specified prior authorization requirements in this section but are generally considered cosmetic and may be denied when performed for appearance alone.
- When the policy does not specify prior authorization, providers should verify benefit plan requirements and submit clinical documentation if coverage is sought.
Documentation to Support Medical Necessity
Providers must submit documentation to support medical necessity with authorization requests. This includes clinical notes, photographs, operative reports, letters describing functional impairment, conservative therapy attempts, and any relevant histopathologic or imaging findings.
- Photographs, chart records, and letters documenting medical necessity may be required for many procedures (e.g., blepharoplasty, liposuction for lipedema).
- For lipedema, include documentation of conservative therapy (manual lymphatic drainage, compression therapy, exercise, skin care) prior to surgical consideration.
Coding Documentation
Accurate coding and submission of applicable procedure and diagnosis codes is required. Some HCPCS codes are listed as covered only if selection criteria are met, while other HCPCS/CPT/ICD‑10 codes are explicitly not covered for certain indications.
- Submit the appropriate CPT/HCPCS procedure codes and ICD‑10 diagnosis codes that reflect medical necessity rather than cosmetic intent.
- Refer to the 'Applicable CPT / HCPCS / ICD‑10 Codes' lists in the policy for covered vs not‑covered codes and for codes that may trigger additional review.
Lipedema Diagnostic and Documentation Expectations
For lipedema, diagnosis should be established by history and clinical findings. Providers should document symptom progression, prior conservative treatments, and measurements (e.g., limb circumferences, BMI) when requesting coverage for liposuction or other surgical interventions.
- Diagnosis based on localized, symmetrical increase in subcutaneous adipose tissue disproportionate to trunk, with edema, easy bruising, and tenderness.
- Document trials of conservative therapy (manual lymphatic drainage, compression, exercise, skin care), objective measures (waist/limb circumferences, BMI), and impact on function prior to surgery.
Step Therapy
Step therapy requirements are not described for collagenase (Qwo) or other products in this section; when step therapy is relevant, it will be specified in the applicable coverage criteria or benefit documents.
- No step therapy rules for Qwo are listed in this policy section.
- Verify plan‑specific medical management rules (step therapy, quantity limits) during prior authorization.
Background
Background: Aetna excludes coverage for cosmetic surgery and procedures that are not medically necessary. Procedures that are needed to improve the functioning of a body part, to treat injury, disease, or congenital defects, or that meet specific CPB criteria (for example, reconstruction following mastectomy or surgery for gender dysphoria when criteria are met) may be covered even if they also alter appearance. The policy underscores that cosmetic procedures intended solely to improve appearance are excluded and may be denied.
Definitions
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