CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Cosmetic Services — Procedures

Defines cosmetic procedures that are excluded from coverage under Blue Cross Blue Shield - Rhode Island commercial products and BlueCHiP for Medicare, and directs providers to related surgical policies for procedures that may be covered when functional impairment is documented.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCosmetic Services — Procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 5, 2007

Next Review DateN/A

Key ActionDocument functional impairment and follow the medical necessity criteria in the relevant procedure-specific policy when a procedure might not be cosmetic.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~30listed cosmetic procedures/exclusions

BlueCHiPMedicare product exclusion stated

See relatedRelated policies referenced

Not applicableMedical criteria/prior auth

Coverage Criteria and Exclusions

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Coverage and exceptions

Cosmetic procedures are generally excluded; may be considered for coverage when a documented functional impairment or therapeutic indication exists and the medical necessity criteria of the applicable procedure‑specific policy are met.

General exclusion: Procedure is cosmetic (performed primarily to improve appearance, self‑esteem, or for psychological/psychiatric reasons)

Cosmetic procedures are not covered under this policy for commercial products; claims for cosmetic services are not covered under BlueCHiP for Medicare as not reasonable and necessary.

Exceptions: Procedure is required for prompt repair of accidental injury OR to improve functioning of a malformed body member OR is therapeutic (for example treatment of severe burns) where the primary purpose is functional improvement

Such cases may be considered under other medical necessity policies and must meet the medical necessity criteria in the relevant procedure‑specific policy.

The following procedures are listed as contract exclusions for commercial products and are considered cosmetic: Abdominoplasty; Brow surgery/ptosis; Cervicoplasty; Chemical exfoliations/peels/dermabrasions for acne, scarring, wrinkling, sun or other benign conditions; Correction of variations in normal anatomy including augmentation mammoplasty and correction of congenital breast asymmetry; Dermabrasion; Ear piercing or repair of a torn earlobe; Excision of excess skin or subcutaneous tissue (except panniculectomy); Genioplasty; Hair transplants; Inverted nipple surgery; Hair removal (including electrolysis/epilation); Laser treatment for acne and acne scars; Osteoplasty (facial bone reduction); Otoplasty; Removal of asymptomatic benign skin lesions; Procedures to correct visual acuity (including cornea surgery or lens implants); Repeated cauterizations/electrofulguration to remove growths; Rhinoplasty; Rhytidectomy; Sclerotherapy for spider veins; Scar revision regardless of symptoms; Skin tag removal; Suction-assisted lipectomy; Subcutaneous injection of filling material; Tattooing or tattoo removal (except nipple/areola tattooing related to mastectomy); Treatment of vitiligo; Testicular prosthesis surgery.

Cosmetic surgery and associated expenses are not covered when performed solely to improve appearance, self-esteem, or for psychological reasons; such services are considered not reasonable and necessary. Providers should note that procedures listed as cosmetic exclusions for commercial products may be denied per the member's benefit booklet, and BlueCHiP for Medicare specifically excludes cosmetic surgery and related expenses unless an exception applies.

Provider Actions and Requirements

Prior Authorization
Prior Authorization Required
Preauthorization is required for several related surgical procedures. Submit requests via Blue Cross Blue Shield of Rhode Island's web-based preauthorization tool and follow the specific related medical policy for criteria.
Use the web-based preauthorization tool for listed procedures.
Ensure requests reference the specific related policy being considered.

Denial Risk
Coverage Exclusion / Denial Risk
Claims for cosmetic services are not covered under BlueCHiP for Medicare and will be denied as not reasonable and necessary. Commercial products similarly exclude purely cosmetic procedures unless otherwise specified in the individual policy.
Cosmetic procedures without documented functional impairment will be denied for Medicare members.
For commercial members, review the individual medical policy for exceptions.

Documentation Required
Documentation Required for Possible Coverage
Procedures that have a documented functional impairment may be considered for coverage if they meet the medical necessity criteria in the applicable individual medical policies. Providers must document the functional impairment, clinical findings, and how the procedure meets the medical necessity requirements.
Include objective documentation of functional impairment and prior conservative treatments where applicable.
Reference and satisfy the medical necessity criteria in the related policy when submitting preauthorization and claims.

Billing Rule
Provider/Billing Note
Medical and hospital services related to treatment of complications from non-covered procedures may be required; bill accordingly and be aware that the underlying cosmetic procedure may remain non-covered.
Care for complications may be payable even if the original procedure was non-covered; document the complication and medical necessity.
Confirm coverage policies for complications in the applicable related policy before submission.

Definitions

Cosmetic — definition

DefinitionProcedures performed primarily to refine or reshape body structures that are not functionally impaired to improve appearance, self-esteem, or for psychological/psychiatric/emotional reasons.

Coverage stanceCosmetic procedures are generally excluded from coverage; refer to individual procedure-specific policies for cases that might not be cosmetic.

When to consider other policiesIf a procedure could be non-cosmetic or is intended to address functional impairment, follow the medical necessity criteria in the relevant related-policy documents.

Exceptions to cosmetic exclusion

Prompt repair after accidental injuryProcedures required for prompt (as soon as medically feasible) repair of accidental injury are exceptions to the cosmetic exclusion (e.g., surgery after serious automobile accident).

Improvement of function of malformed body memberSurgery intended to improve the functioning of a malformed body member is not excluded as cosmetic.

Therapeutic surgery with incidental cosmetic effectTherapeutic procedures (for example treatment of severe burns) whose primary purpose is functional or medical are not excluded even if they have cosmetic effect.

Background

Cosmetic procedures are intended to alter appearance or refine body structures primarily for non‑functional reasons such as improving appearance, self‑esteem, or psychological benefit. Because these procedures do not treat a functional impairment, they are generally excluded from coverage. Exceptions exist when the procedure is required for the prompt repair of accidental injury, to improve the functioning of a malformed body member, or when the primary purpose is therapeutic (for example treatment of severe burns), in which case coverage may be considered under applicable medical necessity policies.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCosmetic Services — Procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 5, 2007

Next Review DateN/A

Key ActionDocument functional impairment and follow the medical necessity criteria in the relevant procedure-specific policy when a procedure might not be cosmetic.

SourceLink

On This Page

OpenPayer

Cosmetic Services — Procedures

Coverage Criteria and Exclusions

Coding

Provider Actions and Requirements

Definitions

Background