Cosmetic and Reconstructive Surgery with Attached Companion Table
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Defines CareFirst coverage stance distinguishing cosmetic versus reconstructive surgical procedures, documentation review process, prior authorization note, and that reconstructive surgery is medically necessary while cosmetic is not; applies to members and providers under CareFirst benefit plans.
Cosmetic and Reconstructive surgical procedures are considered medically necessary for ages 5 and below.
Coverage Criteria
Medical Necessity Determinations
Covered when the following determinations apply:
Added per 2023 update
Cosmetic surgical procedures are considered not medically necessary. This general exclusion applies when the primary intent of the procedure is to improve appearance rather than to restore function or correct deformity. Providers should expect such procedures to be denied unless the clinical record demonstrates an applicable exception under this policy.
Coverage for the services described in this policy may vary by contract and by line of business. Verify a member's specific benefits and any prior authorization requirements with the member's plan before scheduling or performing services covered by this policy.
Procedures performed with the primary intent to improve appearance (cosmetic) are considered not medically necessary. Exceptions include patients aged 5 years and younger—for whom cosmetic and reconstructive surgical procedures are considered medically necessary—and treatment of systemic complications (for example, sepsis, hemorrhage, or infection) that arise from any surgical procedure.
Provider Actions and Requirements
Prior Authorization Required
Some services, devices, drugs, and places of service require prior authorization. Providers must submit preauthorization requests online at www.provider.carefirst.com or call 1-866-773-2884 (1-866-PRE-AUTH) before performing services that require approval.
- Submit preauthorization requests online or by phone: www.provider.carefirst.com or 1-866-773-2884 (1-866-PRE-AUTH).
- Verify the member's contract and line of business — prior authorization requirements vary by contract.
Medical Review and Potential Denial
When a procedure has both cosmetic and reconstructive components (mixed-indication), the Plan will medically review submitted documentation to determine primary intent. Procedures not listed in the policy or with unclear clinical intent will be subject to medical review and may be denied if documentation is insufficient to support medical necessity.
- Procedures not explicitly listed must be medically reviewed by the Plan.
- Lack of adequate documentation or unclear indication may lead to denial of coverage.
Required Documentation for Mixed-Indication Procedures
For mixed-indication procedures, include complete supporting documentation with the authorization or claim submission so the Plan can determine whether the procedure is primarily reconstructive or cosmetic.
- History and physical exam report
- Operative report and discharge summary
- Pathology report (if applicable)
- Preoperative photographs when relevant
- Any additional clinical notes demonstrating functional impairment or reconstructive need
Supporting Documentation Sources and Verification Risk
Specialty society position statements, clinical guidelines, and payer manuals may be used as supporting sources during medical review to substantiate coverage determinations. Always verify contract-specific coverage prior to proceeding.
- Use specialty society guidance (e.g., ASPS, AACE) and payer manuals as supporting evidence.
- Verify coverage and prior authorization requirements for the member's specific contract/line of business.
Definitions
Background
This policy distinguishes cosmetic versus reconstructive procedures based on intent and clinical need: cosmetic procedures are performed primarily to improve appearance and are generally not medically necessary, while reconstructive procedures are performed to improve or restore bodily function or correct deformity and are considered medically necessary. Note that the policy makes specific exceptions—both cosmetic and reconstructive procedures are considered medically necessary for patients aged 5 years and below and treatment for systemic surgical complications is considered medically necessary. Because coverage can vary across contracts and lines of business, providers should confirm benefit applicability and any authorization requirements with the member's plan.
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