Baylor Scott & White Cosmetic Procedures Coverage

Coverage Criteria: Cosmetic vs Medically Necessary Procedures

inv-01: Always Cosmetic / Excluded Procedures

Always considered cosmetic when performed without documented functional impairment or other qualifying indications.

Always cosmetic examples: Aesthetic alteration of the female genitalia (e.g., hymenoplasty, inverted V hoodoplasty, labiaplasty, mons pubis-pexy); vaginal rejuvenation procedures (clitoral reduction, designer vaginoplasty, revirgination, G-spot amplification, pubic liposuction/lift, reduction of labia minora/majora, thermal or laser vaginal tightening); aesthetic operations on the umbilicus; breast augmentation (implants) unless required under WHCRA; breast lift (mastopexy); buttock lift or augmentation; cheek (malar) implants; chin implant (genioplasty/mentoplasty) when performed for appearance alone; correction of diastasis recti abdominis; correction of inverted nipple unless related to cancer surgery; ear or body piercing; electrolysis or laser hair removal; excision of excessive skin (thigh lift, arm lift/brachioplasty, forearm/hand, submental fat pad, other areas) performed for cosmetic purposes; intense pulsed light for facial redness; lacrimal gland resuspension for prolapse; mesotherapy; neck tucks; removal of frown lines or spider angiomata; removal of supernumerary nipples; salabrasion; selective neurectomy of gastrocnemius for calf contouring; surgery for body dysmorphic disorder; surgery to correct moon face or tuberous breast deformity; surgical depigmentation of nevus of Ito/Ota; tattoo removal; treatment with small or large gel-particle hyaluronic acid fillers for cosmetic contouring or wrinkle improvement.

See policy text for full list and examples (chunks 3-4).

Procedures identified as cosmetic in policy text: Procedures primarily to alter or enhance appearance without documented impairment of physical function are considered cosmetic and excluded from coverage.

Policy exclusion statement (chunk 1/brief).

inv-02: May Be Medically Necessary When Criteria Met (selected procedures)

Covered when ALL of the following applicable procedure-specific criteria are met.

Abdominoplasty: May be considered medically necessary when surgery is performed to alleviate complicating factors such as inability to walk normally, chronic pain, ulceration from the abdominal skin fold, or intertriginous dermatitis.

Code: 15847. Reference InterQual/L35090 (chunk 5).

Blepharoplasty: May be considered medically necessary when applicable InterQual criteria are met.

Codes: 15820-15823. Reference InterQual L35004 (chunk 5).

Breast reduction: May be considered medically necessary when criteria are met.

Code: 19318. Reference Med Policy 209 (chunk 5).

Chemical peels:

inv-03: Maxillofacial and Orthognathic Surgery Criteria

Maxillofacial and orthognathic surgery coverage depends on the presence of functional impairment; procedures performed solely for appearance are generally considered cosmetic.

Maxillofacial procedures: Generally considered cosmetic and not a covered benefit except when performed as a result of trauma or injury for the purpose of reconstructing tissues/body structures or repairing damaged tissues.

Codes referenced: 21082, 21083, 21087, 21088, 21089 (chunk 8).

Mandible augmentation: May be considered medically necessary when InterQual criteria are met (functional or reconstructive indications required).

Codes: 21125, 21127 (chunk 8/brief).

Orthognathic surgery: Considered cosmetic when performed in the absence of significant functional impairment (including when used solely to alter bite or appearance); coverage requires significant functional impairment per InterQual.

Codes: 21193, 21194, 21198, 21199, 21206, 21208, 21210, 21215 (chunks 8-9,16).

BSWHP considers procedures performed primarily to alter or enhance appearance to be cosmetic and therefore excluded from coverage when there is no documented impairment of physical function. Coverage may be provided, however, when the same surgery is medically necessary to improve the functioning of a body part or to treat an identified medical condition (for example to improve ambulation, relieve intertriginous dermatitis, treat ulceration, or restore respiratory function). Providers should confirm member-specific benefit plan details for exceptions and plan-specific rules.

Panniculectomy may be considered medically necessary when the applicable criteria are met (see InterQual reference L35090). Panniculectomy is NOT covered when performed as an adjunct to other medically necessary procedures (for example, hysterectomy or ventral/incisional hernia repair) unless the panniculectomy criteria are independently met.

The provided excerpts do not contain an expanded list of explicit exclusions beyond the policy's general statement that procedures performed to alter appearance without documented functional impairment are considered cosmetic. Refer to the full policy text for the complete exclusion list and any plan-specific exceptions.

Genioplasty (chin implant/mentoplasty) is listed among procedures considered cosmetic. When performed alone or solely for appearance or orthognathic/esthetic purposes, chin augmentation is not a covered benefit unless there is an independent, documented functional impairment or other qualifying indication referenced elsewhere in the policy or an exception applies (see related policy references).

Within the provided policy excerpts there are no separate explicit 'Not Medically Necessary' statements beyond the general policy direction that cosmetic-only procedures may be excluded. For determinations, reviewers should apply the policy’s functional impairment criteria and any procedure-specific criteria listed elsewhere in the full document.

Relevant CPT/HCPCS/Procedure Codes

Covered/May be considered medically necessary (examples)CPTCovered

15847	Abdominoplasty
15820	Blepharoplasty
15821	Blepharoplasty
15822	Blepharoplasty
15823	Blepharoplasty
19318	Breast reduction
15788	Chemical peel
15789	Chemical peel
15792	Chemical peel
15793	Chemical peel

Injectables and craniofacial procedures referencedCPT | HCPCS | mixedCovered

11950	Dermal filler injection
11951	Dermal filler injection
11952	Dermal filler injection
11954	Dermal filler injection
G0429	Dermal/subcutaneous filler (G code) - breast reconstruction context
21120	Genioplasty
21121	Genioplasty
21122	Genioplasty
21123	Genioplasty

Craniofacial/maxillofacial/reconstructive codesCPT

21082	Maxillofacial procedure
21083	Maxillofacial procedure
21087	Maxillofacial procedure
21088	Maxillofacial procedure
21089	Maxillofacial procedure
21125	Mandible augmentation
21127	Mandible augmentation
21175	Reconstructive surgeries involving bones of skull and face
21183	Reconstructive surgeries involving bones of skull and face
21193	Orthognathic surgery

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Rhinoplasty codesCPT

30400	Rhinoplasty
30410	Rhinoplasty
30420	Rhinoplasty
30430	Rhinoplasty
30435	Rhinoplasty
30450	Rhinoplasty
30460	Rhinoplasty

Facial/skin/scar procedure codesCPTCovered

15824	Rhytidectomy
15825	Rhytidectomy
15826	Rhytidectomy
15828	Rhytidectomy
15829	Rhytidectomy
15786	Scar revision
11200	Skin tag removal
11201	Skin tag removal
11920	Tattoo reconstruction (breast)
11921	Tattoo reconstruction (breast)

1–10 of 11

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No codes listed in excerptmixed

No codes listed

Chemical peel lesion count — threshold details (>= 15 lesions)

Threshold>= 15 lesions (for actinic keratoses or other pre-malignant skin lesions)

Required prior therapyTrial of topical 5-fluorouracil (5-FU) or imiquimod unless contraindicated

Applicable codesCPT 15788, 15789, 15792, 15793

Coding observations

Coding observationsNone in excerpt

Notes

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization Required — Certain procedures within this policy require prior authorization. Providers should verify prior authorization requirements with the member’s specific Baylor Scott & White Health Plan product and submit any required prior authorization requests before performing services to avoid claim denials or payment delays.

Check member benefit plan document for prior authorization rules and any plan-specific exclusions or limits.
Prior authorization submission may require clinical documentation demonstrating medical necessity.

Documentation Required

Documentation for Medical Necessity

Document medical necessity thoroughly. The requesting physician may be required to submit supporting documentation such as clinical chart notes, operative reports, photographs, and letters describing functional impairment or other medical reasons for the procedure. Lack of adequate documentation (for example, absence of documented functional impairment when a procedure is cosmetic in nature) creates high risk for denial.

Background and Scope

This policy defines cosmetic procedures as surgeries or treatments performed primarily to alter or enhance appearance in the absence of documented physical functional impairment. The policy supplements plan language by listing examples of procedures that are typically considered cosmetic (such as genitoplasties, breast augmentation, chin implants, tattoo removal, and many others) and identifies procedures that may be medically necessary when specific clinical criteria are met (for example abdominoplasty, blepharoplasty, panniculectomy, chemical peels, dermabrasion, and nasal surgery when performed to improve respiratory function). Emotional or psychosocial concerns alone do not constitute the physical functional impairment required for coverage decisions.

Definitions and Key Terms

Abdominoplasty definition and notes on scope

DefinitionAbdominoplasty: surgical excision of skin and subcutaneous fat in the abdomen; may include secondary nonfunctional procedures (e.g., transposition of the umbilicus, repair of lax abdominal muscles, suction-assisted liposuction).

ScopeProduces a flatter, firmer abdomen and is primarily cosmetic; considered an add-on procedure and not covered when performed solely for cosmetic improvement (often additive to panniculectomy).

When may be necessaryMay be considered medically necessary to alleviate complicating factors such as inability to walk normally, chronic pain, ulceration from abdominal skin fold, or intertriginous dermatitis (see criteria reference L35090).

Panniculectomy definition

DefinitionPanniculectomy: surgical excision of redundant (excess) hanging abdominal skin and fat (panniculus), not including muscle plication or neoumbilicoplasty as in an abdominoplasty.

Policy Revision History and Changes

2025-10-01effective_dateLatest

Policy effective date set to 2025-10-01.

2025-08-11revision

Reviewed and updated: removed reference to Medicare NCD/LCD InterQual criteria and added multiple CPT codes and guidance for genioplasty, maxillofacial procedures, mandible augmentation, orthognathic surgery, reconstructive surgeries of skull and face, and rhinoplasty.

2025-03-10revision

Reviewed: removed reference to a retired policy and added CPT codes 15792 and 15793 to the Chemical Peels ending note; updated ending note to align with business entity changes.

OpenPayer

Cosmetic Procedures and Treatment