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    v1.0.28
    OpenPayerPolicy UpdatesPlastic/Reconstructive SurgeryAmbetter Nevada Cosmetic Policy Update | OpenPayer
    Ask Trek AI about this page
    ModifiedAmbetter NevadaPolicy CP.MP.31

    Cosmetic and Reconstructive Procedures

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    Establishes medical-necessity criteria for reconstructive procedures and identifies cosmetic procedures that are generally not medically necessary or covered for providers submitting services to affiliated health plans in Nevada, excluding Medicare-plan criteria and procedure-specific policies.

    Policy Summary
    PayerAmbetter Nevada
    PolicyCosmetic and Reconstructive Procedures
    Policy CodePolicy CP.MP.31
    Change TypeModified
    Effective DateN/A
    Last ReviewAug 1, 2026
    Next Review DateN/A
    Key ActionFor reconstructive procedures intended to improve function, document failure of conservative therapy unless it is not standard of care or is contraindicated.
    SourceLink
    POLICY UPDATE CHANGES

    The August 2026 revision added CPT codes 54163, 54360, 54380, 54385, and 54390 for penile and circumcision-related procedures.

    The August 2026 revision combined criteria sections I and A and removed former criteria I.A.1 through I.A.3.

    The policy previously added craniofacial reconstruction and craniosynostosis codes transferred from the retired Craniofacial Surgery policy.

    The policy added CPT codes 19330 and 19499 for breast-related services during a prior revision.

    CPT code 11310 was removed during a prior annual review.

    The policy clarified that failure of conservative therapy is required unless conservative therapy is not standard of care or is contraindicated.

    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.

    2Reconstructive coverage pathways
    21Cosmetic procedures generally not covered
    1Conservative-therapy requirement
    43CPT codes listed
    3HCPCS codes listed
    08/26Latest revision

    Medical Necessity and Coverage Criteria

    Reconstructive procedures

    Reconstructive procedures are medically necessary when either of the following pathways is met:

    ONE of the following

    • Functional reconstruction

      • The procedure is intended to improve the function of an abnormal body part caused by illness, trauma, or a congenital defect.
      • Conservative therapy has failed.

        Conservative therapy is not required when it is not standard of care for the condition or is contraindicated.

    • Specified appearance-related reconstructive procedures

      • Following post-mastectomy, medically necessary lumpectomy, or other medically necessary breast surgery resulting in asymmetry, the procedure is breast reconstruction, including nipple reconstruction, tattooing, or surgery on the contralateral breast to restore symmetry.
      • The procedure uses FDA-approved facial dermal injections—Poly-L-Lactic acid (Sculptra) or calcium hydroxylapatite microspheres (Radiesse)—or autologous fat transfer for HIV-associated facial lipodystrophy syndrome.

    Cosmetic procedures

    Cosmetic surgery is generally not medically necessary and generally not a covered benefit when:

    The procedure is performed to improve the appearance of normal body structures or self-esteem.

    This includes procedures performed solely for cosmetic purposes. Examples include excision of excessive skin, body contouring or body lift, breast augmentation, cosmetic liposuction, facial augmentation, abdominoplasty, skin rejuvenation or resurfacing, electrolysis or laser hair removal, and hair transplantation not correcting permanent disease- or injury-related hair loss.

    The following procedures are generally considered cosmetic, not medically necessary, and not covered when performed to improve normal appearance or self-esteem: excision of excessive skin; body contouring or body lift; breast augmentation; liposuction, except for lipoma when directed by clinical decision support criteria; correction of unsatisfactory results from prior cosmetic or non-covered services; revision, removal, or replacement of breast implants placed for cosmetic reasons; facial augmentation; abdominoplasty; dermabrasion; skin rejuvenation or resurfacing; electrolysis or laser hair removal; tattooing except for covered post-mastectomy breast reconstruction; injectable filler except for the specified HIV-associated facial lipodystrophy indication; circumcision revision solely to improve appearance; mastopexy except for specified breast-reconstruction indications; 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.

    Surgery performed to reshape normal body structures to improve appearance or self-esteem is generally considered not medically necessary and is generally not a covered benefit. Coverage may be considered only when the procedure meets a specified reconstructive indication rather than serving solely a cosmetic purpose.

    Removal of excess skin or body contouring following weight loss or bariatric surgery is not medically necessary when the removal is performed solely for cosmetic reasons.

    Hair transplantation is not medically necessary when it is not performed to correct permanent hair loss caused by disease or injury. Hair transplantation may be considered when it addresses permanent hair loss resulting from disease or injury, rather than being performed solely for cosmetic improvement.

    Procedure and Billing 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
    11400Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less
    11401Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm
    11402Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm
    11403Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm
    11404Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm
    11406Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm
    11420Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less
    11421Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm
    1–10 of 89
    1/9
    CPT CodesCPT
    21120Genioplasty; augmentation
    21121Genioplasty; sliding osteotomy, single piece
    21122Genioplasty; sliding osteotomies, 2 or more osteotomies
    21123Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)
    21137Reduction forehead; contouring only
    21138Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft)
    21139Reduction forehead; contouring and setback of anterior frontal sinus wall
    21159Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, monobloc), requiring bone grafts (includes obtaining autografts); without LeFort I
    21160Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, monobloc), requiring bone grafts (includes obtaining autografts); with LeFort I
    21172Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts)
    1–10 of 43
    1/5
    HCPCS CodesHCPCS
    G0429Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) as a result of highly active antiretroviral therapy
    Q2026Injection, Radiesse, 0.1 ml
    Q2028Injection, Sculptra, 0.5 mg
    Lesion or graft size
    Benign-lesion excisionExcised diameter ranges from 0.5 cm or less through over 4.0 cm.
    Tattooing or micropigmentation6.0 sq cm or less; 6.1 to 20.0 sq cm; or each additional 20.0 sq cm, or part thereof.
    Facial fat grafting25 cc or less injectate, followed by each additional 25 cc injectate, or part thereof.
    Trunk, breast, scalp, arm, or leg fat grafting50 cc or less injectate, followed by each additional 50 cc injectate, or part thereof.
    Benign lesion count
    Up to 14 lesionsDestruction of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions.

    Documentation and Coverage Risk

    Documentation Required

    Document Conservative Therapy Failure

    For reconstructive procedures intended to improve the function of an abnormal body part caused by illness, trauma, or a congenital defect, document failure of conservative therapy. The failure requirement does not apply when conservative therapy is not standard of care for the condition or is contraindicated.

    Documentation Required

    Photographs May Be Requested

    Photographs may be requested when applicable. Be prepared to provide relevant photographs as part of the documentation supporting the procedure.

    Denial Risk

    Cosmetic Intent Creates Denial Risk

    Cosmetic surgery is generally not medically necessary and not a covered benefit when performed to improve a patient’s normal appearance or self-esteem. A reconstructive procedure intended only to improve appearance, or involving a normal body part without a qualifying illness, trauma, congenital defect, or policy exception, carries denial risk.

    Policy Context

    Reconstructive surgery is performed on abnormal body structures caused by congenital defects, developmental abnormalities, previous or concurrent surgery, trauma, infection, tumors, or disease. It is generally intended to improve function and may or may not restore normal appearance.

    Key Terms

    Functional impairment
    DefinitionA health condition in which the normal function of a body part or organ system is less than age-appropriate full capacity.
    ExamplesExamples include decreased range of motion and diminished eyesight or hearing.
    Daily activitiesThe condition variably impacts activities of daily living.
    Reconstructive surgery
    DefinitionSurgery performed on abnormal structures caused by congenital defects, developmental abnormalities, previous or concurrent surgeries, trauma, infection, tumors, or disease.
    Primary purposeIt is generally performed to improve the functioning of a body part.
    Policy Summary
    PayerAmbetter Nevada
    PolicyCosmetic and Reconstructive Procedures
    Policy CodePolicy CP.MP.31
    Change TypeModified
    Effective DateN/A
    Last ReviewAug 1, 2026
    Next Review DateN/A
    Key ActionFor reconstructive procedures intended to improve function, document failure of conservative therapy unless it is not standard of care or is contraindicated.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaProcedure and Billing CodesDocumentation and Coverage RiskPolicy ContextKey Terms
    15 or more lesionsDestruction of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions.
    Coding distinctionThe threshold separates benign-lesion destruction procedures into the up-to-14-lesion and 15-or-more-lesion categories.
    Denial Risk

    Missing Conservative-Therapy Documentation

    Functional reconstructive treatment may be denied when the record does not document failure of conservative therapy. The requirement is subject to the exceptions that conservative therapy is not standard of care for the condition or is contraindicated; appearance-only reconstructive procedures may also be covered only when specifically identified as an applicable policy exception.

    Denial Risk

    Listed Cosmetic Procedures

    The following procedures are generally considered not medically necessary and generally are not covered when performed for cosmetic purposes, subject to the stated exceptions and applicable clinical decision support criteria:

    • Excision of excessive skin; body contouring; and body lift.
    • Breast augmentation.
    • Liposuction, excluding lipoma treatment as directed by clinical decision support criteria.
    • Surgery to correct unsatisfactory results from a previous cosmetic or non-covered service.
    • Revision, removal, or replacement of breast implants previously placed for cosmetic reasons.
    • Removal of excess skin or body contouring after weight loss or bariatric surgery when removal is solely cosmetic.
    • Facial augmentation; abdominoplasty; dermabrasion; and skin rejuvenation or resurfacing.
    • Electrolysis and laser hair removal.
    • Hair transplantation when not performed to correct permanent hair loss caused by disease or injury.
    • Tattooing, except when covered for breast reconstruction after mastectomy.
    • Injectable filler, except as specified for FDA-approved facial dermal injections or autologous fat transfer for HIV-associated facial lipodystrophy syndrome.
    • Circumcision revisions performed only to improve appearance.
    • Mastopexy, except for breast reconstruction after mastectomy, medically necessary lumpectomy, or other medically necessary breast surgery resulting in significant asymmetry.
    • Correction of inverted nipples; repair of diastasis recti; and breast reconstruction for fibroadenomas or other benign lesions unless medically necessary under applicable clinical decision support criteria.
    Appearance
    The procedure may or may not restore a normal appearance.
    Cosmetic surgery
    DefinitionSurgery performed to reshape normal structures of the body in order to improve a patient's appearance and self-esteem.
    Structures addressedThe surgery is performed on normal body structures rather than abnormal structures caused by disease, injury, congenital defects, or other conditions.
    Coverage statusIt is generally considered not medically necessary.