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    v1.0.30
    OpenPayerPolicy UpdatesPlastic/Reconstructive SurgeryAmbetter Georgia Cosmetic Coverage | OpenPayer
    Ask Trek AI about this page
    ModifiedAmbetter GeorgiaPolicy CP.MP.31

    Cosmetic and Reconstructive Procedures

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    Establishes medical-necessity criteria for cosmetic and reconstructive surgery, including covered reconstructive indications and procedures generally not medically necessary or covered, for Ambetter Georgia commercial health plans when no more specific procedure policy is available.

    Policy Summary
    PayerAmbetter Georgia
    PolicyCosmetic and Reconstructive Procedures
    Policy CodePolicy CP.MP.31
    Change TypeModified
    Effective DateNov 1, 2026
    Last ReviewAug 1, 2026
    Next Review DateNot specified
    Key ActionDocument the abnormality, resulting functional impairment or reconstructive indication, underlying cause, and conservative treatment failure or why conservative therapy is not standard or is contraindicated.
    SourceLink
    POLICY UPDATE CHANGES

    The 2026 revision added CPT codes 54163, 54360, 54380, 54385, and 54390 to the policy.

    The 2026 revision combined and renumbered the criteria sections and removed the prior I.A.1-I.A.3 structure.

    The policy revision history documents clarification and reformatting of the criteria and coding descriptions during annual review.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    5Added penile and circumcision codes
    21Cosmetic procedures generally not covered
    40+Supporting CPT codes
    PhotosPotential documentation
    3HCPCS codes

    Medical Necessity and Coverage Criteria

    Medically necessary reconstructive procedures

    Reconstructive procedures are considered medically necessary when at least one of the following criteria is met:

    Covered reconstructive indications

    • Functional reconstructive procedure

      • The intent of the procedure is to improve the function of an abnormal body part caused by illness, trauma, or a congenital defect.

        Conservative therapy must have failed unless conservative therapy is not standard of care for the condition or is contraindicated.

    • Appearance-improving reconstructive exceptions

      • Breast asymmetry after medically necessary breast surgery

        • Breast reconstruction, including nipple reconstruction, tattooing, or surgery on the contralateral breast, is performed to restore symmetry after post-mastectomy, medically necessary lumpectomy, or other medically necessary breast surgery.

      • HIV-associated facial lipodystrophy syndrome

        • FDA-approved facial dermal injections, including Poly-L-Lactic acid (Sculptra) or calcium hydroxylapatite microspheres (Radiesse), or autologous fat transfer are used for HIV-associated facial lipodystrophy syndrome.

          The dermal injections must be FDA-approved.

    Procedures performed solely to improve the appearance of a normal body structure or self-esteem are generally not medically necessary and are generally not a covered benefit.

    Tattooing is excluded, except when performed as part of covered breast reconstruction after mastectomy.

    Mastopexy is excluded except when performed for breast reconstruction after mastectomy, a medically necessary lumpectomy, or other medically necessary breast surgery that results in significant asymmetry.

    Injectable fillers are excluded except for the specified indication of HIV-associated facial lipodystrophy syndrome, including the covered FDA-approved treatment described in the policy.

    Hair transplantation is excluded when it is not performed to correct permanent hair loss caused by disease or injury.

    Breast reconstruction for fibroadenomas or other benign lesions is excluded unless it is medically necessary under applicable clinical decision support criteria.

    The following procedures are generally not medically necessary when performed for cosmetic purposes: excision of excessive skin, body contouring, body lift, breast augmentation, cosmetic liposuction, abdominoplasty, facial augmentation, dermabrasion, skin rejuvenation or resurfacing, electrolysis, laser hair removal, cosmetic hair transplantation, non-reconstructive tattooing, cosmetic circumcision revision, correction of inverted nipples, and repair of diastasis recti. This also includes correction of unsatisfactory results from a previous cosmetic or non-covered service; revision, removal, or replacement of breast implants placed for cosmetic reasons; and removal of excess skin or body contouring after weight loss or bariatric surgery when the removal is solely cosmetic. Liposuction for lipoma may be considered as directed by clinical decision support criteria.

    Supporting Procedure Codes

    CPT Codes That Support Coverage CriteriaCPT
    11200Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions
    11201Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof
    11420Excision, benign lesion including margins, except skin tag, scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less
    11421Excision, benign lesion including margins, except skin tag, scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm
    11422Excision, benign lesion including margins, except skin tag, scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm
    11423Excision, benign lesion including margins, except skin tag, scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm
    11424Excision, benign lesion including margins, except skin tag, scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm
    11426Excision, benign lesion including margins, except skin tag, scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm
    11440Excision, other benign lesion including margins, except skin tag, face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less
    11441Excision, other benign lesion including margins, except skin tag, face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm
    1–10 of 59
    1/6
    CPT CodesCPT
    15877Suction assisted lipectomy; head and neck
    15878Suction assisted lipectomy; trunk
    15792Chemical peel, nonfacial; epidermal
    15793Chemical peel, nonfacial; dermal
    17110Destruction of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions
    17111Destruction of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions
    19301Mastectomy, partial
    19302Mastectomy, partial, with axillary lymphadenectomy
    19303Mastectomy, simple, complete
    19316Mastopexy
    1–10 of 71
    1/8
    HCPCS CodesHCPCS
    G0429Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome as a result of highly active antiretroviral therapy
    Q2026Injection, Radiesse, 0.1 ml
    Q2028Injection, Sculptra, 0.5 mg

    Documentation and Submission Guidance

    Documentation Required

    Document Failed Conservative Therapy

    For reconstructive procedures intended to improve function, document that conservative therapy failed before submission, unless conservative therapy is not standard of care for the condition or is contraindicated.

    Documentation Required

    Clinical Photographs

    Photographs may be requested when applicable. Include clinically relevant photographs when they help demonstrate the abnormality, asymmetry, excess tissue, or other condition supporting the request.

    Documentation Required

    Medical-Necessity Support

    Support medical necessity with a complete clinical narrative describing the abnormality and its cause, the resulting functional impairment or qualifying reconstructive indication, the underlying illness, trauma, or congenital defect, and the treatment history, including prior conservative therapy and response. Include relevant examination findings, severity, duration, and other clinical details supporting the requested procedure.

    Policy Background

    Reconstructive surgery addresses abnormal body structures caused by congenital defects, developmental abnormalities, trauma, surgery, infection, tumors, or disease. It is generally performed to improve function and may or may not restore normal appearance. By contrast, cosmetic surgery reshapes normal body structures to improve appearance or self-esteem and is generally considered not medically necessary.

    Key Definitions

    Reconstructive surgery
    DefinitionSurgery performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, previous or concurrent surgeries, trauma, infection, tumors, or disease.
    Usual purposeGenerally performed to improve the functioning of a body part; it may or may not restore a normal appearance.
    Qualifying causes or circumstancesCongenital defects, developmental abnormalities, previous or concurrent surgeries, trauma, infection, tumors, or disease.
    Functional impairment
    DefinitionA health condition in which the normal function of a body part or organ system is less than age-appropriate full capacity.
    ExamplesDecreased range of motion, diminished eyesight, or diminished hearing.
    Policy Summary
    PayerAmbetter Georgia
    PolicyCosmetic and Reconstructive Procedures
    Policy CodePolicy CP.MP.31
    Change TypeModified
    Effective DateNov 1, 2026
    Last ReviewAug 1, 2026
    Next Review DateNot specified
    Key ActionDocument the abnormality, resulting functional impairment or reconstructive indication, underlying cause, and conservative treatment failure or why conservative therapy is not standard or is contraindicated.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaSupporting Procedure CodesDocumentation and Submission GuidancePolicy BackgroundKey Definitions
    • Document when the procedure is intended to improve function of an abnormal body part caused by illness, trauma, or a congenital defect.
    • For reconstructive procedures that may be covered even when improving appearance is the only benefit, document the qualifying indication, such as breast reconstruction after mastectomy, medically necessary lumpectomy, or other medically necessary breast surgery resulting in significant asymmetry.
    • For HIV-associated facial lipodystrophy syndrome, document the diagnosis and use of an FDA-approved facial dermal injection or autologous fat transfer, as applicable.
    Denial Risk

    Cosmetic Intent or Unsupported Procedure

    Flag procedures performed solely to improve a patient’s normal appearance or self-esteem, or procedures lacking a qualifying reconstructive indication, as generally not medically necessary and not a covered benefit.

    • Examples include excision of excessive skin, body contouring or body lift, breast augmentation, liposuction (except lipoma as directed by clinical decision support criteria), abdominoplasty, facial augmentation, dermabrasion, skin rejuvenation or resurfacing, electrolysis or laser hair removal, cosmetic hair transplantation, cosmetic tattooing, injectable fillers outside the specified HIV-associated indication, circumcision revision for appearance, correction of inverted nipples, repair of diastasis recti, and breast reconstruction for fibroadenomas or other benign lesions unless medically necessary under clinical decision support criteria.
    • Also flag surgery to correct unsatisfactory results from a previous cosmetic or non-covered service, and mastopexy unless it is for breast reconstruction after mastectomy, medically necessary lumpectomy, or other medically necessary breast surgery resulting in significant asymmetry.
    Denial Risk

    Cosmetic Implant Revision or Removal

    Revision, removal, or replacement of breast implants originally placed for cosmetic reasons is generally not medically necessary and is generally not a covered benefit.

    • Document the original indication for implant placement and the specific medical or reconstructive indication for any requested revision, removal, or replacement.
    Denial Risk

    Post-Weight-Loss Contouring Without Medical Need

    Removal of excess skin or body-contouring procedures following weight loss or bariatric surgery are generally not medically necessary or covered when the removal is solely cosmetic.

    • Document any qualifying functional impairment, medical complication, or reconstructive indication if the request is not solely intended to improve appearance.
    Daily activitiesThe impact on activities of daily living can vary.
    Cosmetic surgery
    DefinitionSurgery performed to reshape normal structures of the body in order to improve a patient's appearance and self-esteem.
    Medical-necessity statusGenerally considered not medically necessary.
    Covered benefitCosmetic procedures performed solely to improve appearance or self-esteem are generally not a covered benefit.