Use listed CPT/HCPCS codes on PA requests

When requesting prior authorization, reference the specific CPT and HCPCS codes listed in the policy (examples include removal/excision codes 11200–11406, tattooing 11920–11921, breast and reconstructive codes such as 19301, 19350, 19357, 19364, craniofacial and grafting codes 21120–21296, and HCPCS G0429/Q2026/Q2028) and follow the payer's standard prior authorization process.

• Providers should cite the applicable CPT/HCPCS codes from the policy when submitting PA requests.
• Inclusion of a code in the policy is informational and does not guarantee coverage; follow payer PA submission requirements.

PA and decision support required for listed procedures

Prior authorization is implied/required for the reconstructive and cosmetic procedure and injectable filler codes listed in the policy; certain determinations use decision support criteria (formerly InterQual). Follow the Health Plan's PA procedures for these codes.

• Decision support criteria are used for some medical necessity determinations.
• PA requirements apply to listed reconstructive, cosmetic, and injectable filler codes as governed by the Health Plan.

Document reconstructive intent and medical necessity

Ensure documentation supports the reconstructive intent and medical necessity per policy criteria (e.g., functional impairment, failure of conservative therapy when required) and include relevant codes and clinical rationale in the PA or claim submission.

• Document how the procedure meets I.A criteria: improves function of an abnormal body part, or meets listed reconstructive exceptions.
• Include evidence of conservative therapy failure when required by the criteria.

Show failure of conservative therapy when required

Document and demonstrate failure of conservative therapy when required by the criteria; conservative therapy is not required only if it is not standard of care for the condition or is contraindicated.

• Include prior treatments attempted and clinical response in the medical record and PA submission.
• If conservative therapy was not appropriate, document why it was not standard of care or was contraindicated.

Provide photographs when requested

Photographs may be requested to support medical necessity; provide clinical photographs when applicable and available to substantiate the functional or reconstructive need.

• Follow the Health Plan's instructions for submitting images with the PA or medical record.
• Ensure photos are labeled and linked to the patient's record and the specific clinical indication.

Photographic requirement now a discretionary note

The policy converted the previous medical-record photographic requirement to a note; medical record photographic submission is not mandatory but may still be requested by the Health Plan to support medical necessity.

• Photographic requirement removed as mandatory documentation; retain and provide photos if requested.
• Document other clinical records and rationale even if photographs are not available.

Cosmetic procedure requests may be denied

Requests for procedures that are cosmetic (performed to improve normal appearance or self‑esteem) are generally not medically necessary and may be denied; verify the indication meets reconstructive criteria before submission.

• Examples of cosmetic, not medically necessary procedures include abdominoplasty, breast augmentation, injectable filler, and tattooing except when for post-mastectomy reconstruction.
• If procedure is reconstructive, clearly document criteria-based indications (e.g., functional impairment, post-mastectomy asymmetry).

Coverage subject to contract and regulatory requirements

Coverage decisions are governed by the Health Plan's contract terms, exclusions, limitations, and applicable state and federal requirements; if there is a discrepancy between this policy and legal/regulatory requirements, law and regulation control.

• Verify member benefits and contract terms; policy guidance does not guarantee coverage.
• Comply with state/federal rules that may supersede policy language.