Cosmetic and Reconstructive Surgery (Coverage Criteria)
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Defines when surgical and related procedures are reconstructive (medically necessary) versus cosmetic or investigational, lists specific services and required documentation, and notes product-specific prior authorization and benefit variations.
No material clinical or coverage changes in this revision.
Coverage Criteria
General reconstructive surgery criteria
Covered when the service is reconstructive and documentation supports functional impairment or specified indications
Clear and unequivocal documentation in the medical record is required to support reconstructive nature.
Rhinoplasty (functional) criteria
Rhinoplasty considered medically necessary when ALL of the following are met
Includes vestibular stenosis due to trauma, extensive disease, or congenital defect; provide diagnostic study results and documentation of conservative management attempts as appropriate.
Septoplasty criteria
Septoplasty considered medically necessary when used to treat a septal deformity resulting in any of the listed conditions
Document duration/degree of symptoms, results of conservative therapy, and diagnostic studies (e.g., imaging, endoscopy) as applicable. Secondary (revision) septoplasty may be considered medically necessary if primary criteria are met and symptoms persist or worsen.
Enumerated reconstructive procedures
Specific procedures considered medically necessary when criteria met
Many items have procedure-specific documentation requirements (e.g., imaging, trial of conservative therapy, specialty consults).
Coverage Criteria
Coverage is determined by medical necessity and member benefit terms. The policy lists procedures explicitly considered cosmetic (not covered) and procedures covered when medically necessary.
Prior authorization may be required per plan rules; providers should document medical necessity because coding alone does not denote coverage.
Examples of codes designated cosmetic include, but are not limited to, 17340 and codes in the 15771–15774 range. Procedures listed as cosmetic are excluded from coverage and may be denied when billed.
Chemical peels are addressed separately by depth and indication. Epidermal chemical peels performed for photoaged skin, wrinkles, or acne scarring are considered cosmetic and are not covered when used for those cosmetic indications. In contrast, the policy identifies dermal chemical peels as medically supported only when used for specified therapeutic indications (for example, treatment of premalignant/actinic keratoses); dermal peels for purely cosmetic indications such as end‑stage acne scarring are considered investigational or cosmetic and not covered.
Certain procedures are explicitly designated as cosmetic and therefore not covered. The policy provides a list of procedure codes in that section (examples include CPT 17340 and CPT 0419T/0420T and the listed 15771–15774 codes). Services billed with those codes may be denied as cosmetic per the policy.
Some services are categorized as cosmetic or investigational due to insufficient evidence. The policy explicitly calls out the surgical treatment of comedones/milia/pustules, dermal fillers, implants for cosmetic purposes, and facial prostheses for reasons not enumerated in the reconstructive criteria as investigational or cosmetic and therefore not supported for coverage when used for those indications.
The policy history documents prior wording changes: statements previously phrased as “not medically necessary” for certain items have been updated in the record to be described as “investigational” in some instances. The policy history also notes prior language specifying that dermal fillers were considered cosmetic and therefore not medically necessary in earlier versions.
Coding
| 17340 | Procedure code listed as cosmetic (not covered) in policy |
| Q2026 | Procedure code listed as cosmetic (not covered) in policy |
| 69090 | Procedure code listed as cosmetic (not covered) in policy |
| Q2028 | Procedure code listed as cosmetic (not covered) in policy |
| 0419T | Procedure code listed as cosmetic (not covered) in policy |
| 0420T | Procedure code listed as cosmetic (not covered) in policy |
| 15771 | Procedure code listed as cosmetic (not covered) in policy |
| 15772 | Procedure code listed as cosmetic (not covered) in policy |
| 15773 | Procedure code listed as cosmetic (not covered) in policy |
| 15774 | Procedure code listed as cosmetic (not covered) in policy |
| 15789 | Covered when medically necessary |
| 0480T | appears in MN coding mappings and listed in covered when medically necessary |
| 15792 | Mapped in covered list (per document mapping) |
| 10040 | Mapped in covered list (per document mapping) |
| 15793 | Mapped in covered list (per document mapping) |
| 15780 | Mapped in covered list (per document mapping) |
| 15781 | Mapped in covered list (per document mapping) |
| 15782 | Mapped in covered list (per document mapping) |
| 15783 | Mapped in covered list (per document mapping) |
| 15786 | Mapped in covered list (per document mapping) |
Provider Actions and Documentation
Benefit- and product-specific prior authorization
This policy applies only to certain Capital Blue Cross programs and products; benefit determinations vary by plan and prior authorization may be required per member benefit terms.
Prior authorization and medical necessity required
Procedures identified as “Covered when medically necessary” require documentation that demonstrates medical necessity and are subject to the member's benefit terms; prior authorization may be required per plan rules.
- Codes listed in the 'Covered when medically necessary' table require medical necessity documentation.
Document trial of conservative therapy before septoplasty
For septoplasty when treating recurrent sinusitis or CPAP interference, document a recent 4–8 week trial of conservative medical therapy (e.g., decongestants, nasal spray, corticosteroids) that was ineffective before surgery is considered.
- Recurrent sinusitis path requires a recent eight-week trial of conservative medical therapy that was ineffective.
- CPAP interference indication requires a recent four-week trial of conservative medical therapy that was ineffective.
Submit required diagnostic and history documentation for nasal surgery
Provide all required clinical documentation requested for nasal surgery prior authorization and medical review.
- Results of clinically indicated diagnostic studies (e.g., CT or other appropriate imaging).
- Documented severity and duration of symptoms and nasal endoscopy.
- Relevant history of trauma, disease, or congenital defect.
Required documentation for nasal surgery requests
Requests for septoplasty, rhinoplasty, or septorhinoplasty must include diagnostic study results, documentation of symptom severity/duration, nasal endoscopy findings, and relevant history (trauma, disease, congenital defect).
- CT scan or other appropriate imaging to document deformity/obstruction.
- Document severity and duration of symptoms caused by the deformity/obstruction.
- Nasal endoscopy and relevant history of trauma, disease, or congenital defect.
Document conservative management and positive exam findings
For rhinoplasty or septoplasty include documentation of prior conservative management attempts and objective positive physical exam findings when applicable (e.g., positive Cottle maneuver).
- Results of conservative management of symptoms must be documented for rhinoplasty.
- For septoplasty, document failed conservative therapy durations or frequency/duration of sinusitis episodes as specified.
Document medical necessity beyond coding
Document medical necessity in the medical record; the presence of a CPT/HCPCS code alone does not denote coverage because coverage is determined by member benefit terms and documented clinical criteria.
Cosmetic procedure coding denial risk
Procedures and codes listed in the policy as cosmetic are not covered and may result in claim denial when billed under those codes (see 'The following are cosmetic; therefore not covered' list).
- Examples include codes listed in the cosmetic/not covered section (e.g., 17340, 15771–15774 and others).
Denial risk for procedures listed as cosmetic
Services designated as cosmetic in the policy are not covered and may be denied when billed; verify coverage before scheduling or billing.
- Refer to the 'cosmetic; therefore not covered' code list in the policy when submitting claims.
Background
Reconstructive surgery is defined in this policy as procedures performed to improve or correct a functional impairment, restore bodily function, or correct deformity that results from birth defect, disease, or accidental injury. Procedures that do not meet this definition are considered cosmetic. The policy lists examples of reconstructive services that may be medically necessary when documentation supports functional impairment or the specific clinical indications described in the criteria.
Definitions
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