Blue Cross Blue Shield MA plastic surgery Coverage Update

Coverage Criteria for Plastic and Reconstructive Surgery

Reconstructive Surgery - General

Covered when ANY of the following reconstructive or restorative criteria are met

General reconstructive indications: Procedure performed to improve or restore bodily function OR correct a functional impairment caused by an accidental injury, birth defect, prior surgical procedure, or disease.

Includes correction of scarring after accidental face and neck injuries and treatment of complications of cosmetic surgery when the treatment of the complication is medically necessary to restore function. Only the initial reconstructive repair is covered unless the procedure is normally performed in stages.

Congenital and Developmental Deformities in Children

Congenital/developmental deformities in children may be covered when severe or debilitating including but not limited to:

Child congenital deformities: Deforming hemangiomas; pectus excavatum; syndactyly; macrodactylia; and similar severe or debilitating defects.

The child need not have been covered by the payer at birth. Laser treatments of port‑wine stains or hemangiomas of the face and neck are covered and authorizations are not required for such laser treatments in children and adults.

Chest Wall Deformity

Chest wall deformity (pectus) coverage criteria

Pectus excavatum: Considered medically necessary when Haller index is 3.2 or greater OR there is risk of impending cardiovascular or respiratory compromise due to the magnitude of deformity based upon the requesting physician's clinical judgment.Haller index >= 3.2

Haller index threshold of 3.2 is used as a criterion; physician judgment may substitute when risk of compromise is present.

Pectus carinatum: Considered medically necessary when there is risk of impending cardiovascular or respiratory compromise due to the magnitude of deformity based upon the requesting physician's clinical judgment.

Physician clinical judgment regarding risk of compromise governs coverage for pectus carinatum.

Panniculectomy

Panniculectomy coverage criteria — must meet ALL of the following

Panniculectomy main criteria: Performed after significant weight loss to remove a hanging abdominal panniculus of at least grade 2 severity WITH associated symptoms such as recurrent or refractory skin problems (including skin necrosis recalcitrant to conventional wound care), recurrent skin infections refractory to medical treatment (defined as at least two incidents in a 12‑month period), intertriginous rashes or skin ulcerations that do not show signs of healing after at least 8 weeks of active care under the direction of a dermatologist or wound care specialist, OR shoulder/neck/back pain sufficiently severe to interfere with activities of daily living.Panniculus >= grade 2; recurrent infections >=2 in 12 months; non‑healing after >=8 weeks; defer >=12 months post‑bariatric surgery with stable weight for 6 months

Significant weight loss is defined as meeting one of the following: BMI of 30 or less; documented weight loss of 100 pounds or more; or weight loss of 40% or more of the patient's excess body weight. Submission of medical record documentation and preoperative photographs are required. Panniculectomy should be deferred at least 12 months after bariatric surgery with stable weight for at least 6 months.

Skin Treatment and Scar Management

Skin and scar treatments covered when they restore function or treat symptomatic lesions

Dermabrasion and scar treatments: Dermabrasion for dermal restoration after previous surgery or injury; pulsed dye laser for symptomatic hypertrophic scars when there is documented functional impairment; scar surgery or intralesional steroid injection when scar tissue interferes with normal bodily function or causes pain.

Removal of excess skin after significant weight loss may be medically necessary when there are recurrent documented rashes, non‑healing ulcers, or a documented functional impairment such as significant difficulty with activities of daily living.

Nose (Rhinoplasty)

Nasal surgery coverage

Rhinoplasty is considered medically necessary when there is airway obstruction due to deformity, disease, congenital abnormality, or previous therapy that does not respond to septoplasty alone. Reconstructive rhinoplasty is considered medically necessary for repair after accidental injury.

Ears (Otoplasty)

Ear surgery coverage

Otoplasty may be considered medically necessary for unilateral or bilateral congenital absence of the ear (anotia) or for severe microtia (for example, grade III).

Face

Facial plastic surgery coverage

Facial plastic indications: Facial plastic surgery may be considered medically necessary for initial restoration after accidental injury, or to restore bodily function or correct functional impairment caused by an accident, birth defect, prior surgical procedure (including complications of prior cosmetic surgery when the complication results in physical functional impairment), or disease.

Includes procedures to address functional impairment such as facial nerve palsy.

Hair Removal

Hair removal coverage

Hair removal: Electrolysis or laser hair removal may be considered medically necessary when ingrown hairs are responsible for two or more painful cysts, or when performed after treatment of a pilonidal cyst to prevent recurrence. Procedures must be performed by a licensed and/or certified provider.>=2 painful cysts

Musculoskeletal / Labiaplasty

Other musculoskeletal or genital procedures

Musculoskeletal transplants & labiaplasty: Musculoskeletal transplants are medically necessary as an initial repair after accidental injury or to restore bodily function or correct a functional impairment caused by accidental injury, birth defect, prior surgery, or disease. Labiaplasty may be medically necessary for recurrent documented rashes, non‑healing ulcers, or functional impairment in basic activities of daily living.

Plastic or reconstructive surgery for indications other than those listed is not medically necessary.

Not Medically Necessary / Cosmetic

Procedures considered NOT medically necessary

Not medically necessary examples: Diastasis recti repair is considered NOT MEDICALLY NECESSARY; abdominoplasty is considered cosmetic and NOT MEDICALLY NECESSARY; panniculectomy performed in situations that do not meet the specified criteria (including repeat procedures) is considered NOT MEDICALLY NECESSARY.

CPT 15847 (abdominoplasty) is specifically listed as not medically necessary for commercial and Medicare products in this policy.

General coverage disposition and cross-references

Coverage determinations have been revised over time; specific procedures may be covered, not covered, or governed by subscriber certificate or separate policies.

Policy actions and transfers: Multiple procedures and indications have been transferred to other policies (for example, orthognathic surgery procedures moved to policy #179). Coverage for some items and decisions (for example, certain cosmetic services or dental/orthodontic coverage) may be determined by the subscriber certificate. Policy history contains clarifications and revisions to panniculectomy criteria, coding, and other items.

See related policies listed in the policy history and cross‑references for full criteria.

Note: Subscriber certificates exclude coverage for cosmetic services. This policy distinguishes reconstructive procedures that restore bodily function or correct impairments from cosmetic services that are excluded by the subscriber certificate.

Abdominoplasty is explicitly identified in this policy as a cosmetic procedure and is therefore NOT MEDICALLY NECESSARY. The policy states that abdominoplasty is considered cosmetic and NOT MEDICALLY NECESSARY and that panniculectomy (distinct from abdominoplasty) has specific reconstructive criteria.

The policy lists CPT code 15847 (abdominoplasty) — “Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty)” — and designates this procedure as not medically necessary for the described commercial products.

Policy history and cross-referenced entries note that certain services — including abdominoplasty — have been treated as cosmetic and not medically necessary in prior updates, and that coverage for some procedures or repairs may be governed by the subscriber certificate or transferred to other policies. Historically, the policy has clarified that abdominoplasty and similar cosmetic procedures are not covered and that coverage responsibilities for some items are determined by the subscriber certificate.

The policy distinguishes procedures: Diastasis recti repair is considered NOT MEDICALLY NECESSARY. It also states that abdominoplasty is cosmetic and NOT MEDICALLY NECESSARY. By contrast, panniculectomy can be considered reconstructive and MEDICALLY NECESSARY only when all specified criteria are met (performed after significant weight loss to remove a hanging abdominal panniculus of at least grade 2 severity with associated symptoms such as recurrent/refractory skin problems, infections, non-healing ulcers after ≥8 weeks of care, or severe shoulder/neck/back pain interfering with ADLs).

CPT 15847 (abdominoplasty) is explicitly listed in the policy code table for abdominoplasty and is designated as not medically necessary for the commercial and Medicare product types referenced in the policy.

The policy history documents the designation that abdominoplasty is considered cosmetic and not medically necessary (noted in the 12/2018 entry), reinforcing the longstanding exclusion of abdominoplasty as a covered, medically necessary reconstructive procedure.

Coding — CPT / HCPCS / ICD-10

Hair Removal CPT CodesCPT

17380

Electrolysis epilation, each 30 minutes

HIV-associated lipodystrophy CPT CodesCPT

15770	Graft; derma-fat-fascia
15825	Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)
15828	Rhytidectomy; cheek, chin, and neck
15829	Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap
15838	Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad
15839	Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area
15876	Suction assisted lipectomy; head and neck
15877	Suction assisted lipectomy; trunk

HCPCS CodesHCPCS

Q2026	Injection, Radiesse, 0.1 ml
Q2028	Injection, sculptra, 0.5 mg
G0429	Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS)

Dermabrasion CPT CodesCPT

15780	Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)
15781	Dermabrasion; segmental, face
15782	Dermabrasion; regional, other than face
15783	Dermabrasion; superficial, any site (eg, tattoo removal)

Pulsed Dye Laser Treatment CPT CodesCPT

17110	Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions
17111	Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions

Removal of Excess Skin CPT CodesCPT

15832	Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
15833	Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg
15834	Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip
15835	Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock
15836	Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm
15837	Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand
15838	Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad
15839	Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area

Labiaplasty CPT CodesCPT

56620

Vulvectomy simple; partial

Scars (Intralesional Injection) CPT CodesCPT

11900	Injection, intralesional; up to and including 7 lesions
11901	Injection, intralesional; more than 7 lesions

Rhinoplasty CPT CodesCPT

30400	Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
30410	Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip
30420	Rhinoplasty, primary; including major septal repair
30430	Rhinoplasty, secondary; minor revision (small amount of nasal tip work)
30435	Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)
30450	Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)

Congenital Chest Wall Deformity CPT CodesCPT

21740	Reconstructive repair of pectus excavatum or carinatum; open
21742	Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy
21743	Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy

Panniculectomy CPT CodesCPT

15830

Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy

Lipectomy/Liposuction CPT CodesCPT

15876	Suction assisted lipectomy; head and neck
15877	Suction assisted lipectomy; trunk
15878	Suction assisted lipectomy; upper extremity
15879	Suction assisted lipectomy; lower extremity

Rhytidectomy CPT CodesCPT

15824	Rhytidectomy; forehead
15825	Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)
15826	Rhytidectomy; glabellar frown lines
15828	Rhytidectomy; cheek, chin, and neck
15829	Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap

Otoplasty CPT CodesCPT

69300

Otoplasty, protruding ear, with or without size reduction

Abdominoplasty CPT Code (Not Medically Necessary)CPTNot Covered

15847

Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication)

Coding clarifications referencedmixed

No codes listed

inv-37: Haller index — clinical threshold value

Haller index thresholdHaller index >= 3.2

Clinical alternativeOr risk of impending cardiovascular or respiratory compromise based on physician judgment

ContextApplies to correction of pectus excavatum for medical necessity determinations

Provider Actions, Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required for Inpatient Services

Precertification/preauthorization is required for inpatient procedures described in this policy. Failure to obtain the required inpatient authorization may result in denial of coverage.

Applicable to all products when the procedure is performed inpatient.

Prior Authorization

Outpatient Prior Authorization — Procedures and Product-Specific Requirements

Outpatient prior authorization is required for specific procedures and product types as indicated in the policy code tables. Absence of required outpatient authorization may result in denial or noncoverage for the listed procedures.

Dermabrasion codes (15780–15783) — outpatient prior authorization required for all products.
Removal of excess skin codes (15832–15839) — outpatient prior authorization required for all products.
Rhinoplasty codes (30400–30450) — outpatient prior authorization required for all products.

Background

This policy defines the scope for plastic and reconstructive surgery: services described include congenital deformities, reconstructive surgery, skin treatments, facial plastic surgery, hair removal, chest wall deformity, and musculoskeletal transplants. It emphasizes that the policy addresses when procedures are considered MEDICALLY NECESSARY to restore physical function or correct impairments from accidents, injuries, birth defects, prior surgery, or disease, and that complications of cosmetic surgery may be medically necessary when treatment of the complication restores function.

Key Definitions

inv-56: Significant weight loss definition — BMI of 30 or less; documented weight loss of 100 pounds or more; weight loss of 40% or more of the patient's excess body weight.

BMI criterionBMI of 30 or less

Absolute weight-loss criterionDocumented weight loss of 100 pounds or more

Relative weight-loss criterionWeight loss of 40% or more of the patient's excess body weight

inv-57: Recurrent — defined as at least two incidents in a 12-month period.

Definition of recurrentAt least two incidents in a 12-month period

Context applied toRecurrent skin infections refractory to medical treatment in panniculectomy criteria

Policy Revision History

2026-05clarificationLatest

Clarified coding information.

2025-11revision

Panniculectomy statement clarified; added not medically necessary statement and clarified definition of significant weight loss.

2025-06removal

OpenPayer

Plastic and Reconstructive Surgery — Coverage Criteria