ModifiedCareFirstPolicy 7.01.017

Cosmetic and Reconstructive Surgery with Attached Companion Table

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.

Policy Summary

PayerCareFirst

PolicyCosmetic and Reconstructive Surgery with Attached Companion Table

Policy CodePolicy 7.01.017

Change TypeMaterial clinical update (age exception added)

Effective Date

Next Review Date

Key ActionVerify member benefits and obtain prior authorization when required; submit supporting documentation (history and physical, operative report, photos) for mixed cosmetic/reconstructive cases.

SourceLink

POLICY UPDATE CHANGES

Cosmetic and Reconstructive surgical procedures are considered medically necessary for ages 5 and below.

11+distinct sections

0-5age exception

11/01/2023Last review

02/01/2025Last revision

1998Original approval

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Coverage Criteria

Medical Necessity Determinations

Covered when the following determinations apply:

General coverage rules: Cosmetic surgical procedures are considered not medically necessary. Reconstructive surgical procedures are considered medically necessary.

Age exception: Cosmetic and Reconstructive surgical procedures are considered medically necessary for ages 5 and below.age <= 5 years

Added per 2023 update

Complication care: When a systemic complication such as sepsis, hemorrhage, infection, or other serious documented medical complication occurs as a result of any surgical procedure, treatment of the complication is considered medically necessary.

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

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.

Denial Risk

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.

Definitions

Cosmetic surgery — definition describing primary intent to improve appearance

DefinitionOperative procedures performed with the primary intent to improve appearance, not to restore bodily function or to correct deformity resulting from disease, accidental injury, trauma, infection, congenital defects, or previous therapeutic intervention.

Coverage implicationProcedures performed with cosmetic intent are considered not medically necessary under this policy (except as noted for ages 5 and below).

Mixed-indication noteSome surgeries may have both cosmetic and reconstructive components; primary intent determines coverage classification.

Reconstructive surgery — definition describing restoration of function or correction of deformity

DefinitionOperative procedures performed on structures of the body to improve or restore bodily function or to correct deformity resulting from disease, accidental injury, trauma, infection, congenital defects, or previous therapeutic intervention.

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.

Policy Summary

PayerCareFirst

PolicyCosmetic and Reconstructive Surgery with Attached Companion Table

Policy CodePolicy 7.01.017

Change TypeMaterial clinical update (age exception added)

Effective Date

Next Review Date

SourceLink

On This Page

Procedures not explicitly listed must be medically reviewed by the Plan.
Lack of adequate documentation or unclear indication may lead to denial of coverage.

Documentation Required

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

Note

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.

Coverage implicationReconstructive procedures are considered medically necessary when performed to restore function or correct deformity.

Mixed-indication noteWhen a procedure has both reconstructive and cosmetic components, documentation of the underlying indication is required to determine primary intent.

Therapeutic intervention — definition used in policy context (medically necessary surgical treatment)

Definition (policy use)Any medically necessary surgical treatment (for the purposes of this policy).

ContextTherapeutic interventions are evaluated based on medical necessity and underlying indication to distinguish reconstructive versus cosmetic intent.

DocumentationMedical records must support that the intervention is medically necessary (history, exam, operative reports, etc.) when intent is unclear.

Lipectomy / Abdominoplasty / Lipoplasty references — specialty society and guidance sources

ASPRS/ASPS guidanceAmerican Society of Plastic and Reconstructive Surgeons (ASPRS) and American Society of Plastic Surgeons (ASPS) position statements and procedure-specific guidance on abdominoplasty, lipoplasty, and treatment of skin redundancy following massive weight loss are cited.

AACE position statementAmerican Association of Clinical Endocrinologists (AACE) position statement on prevention, diagnosis, and treatment of obesity is referenced for context on lipectomy.

Technology assessments and payer manualsHayes assessments (e.g., liposuction for lipedema; panniculectomy reports) and MCG Health guidance (Panniculectomy, 26th edition) are listed among supporting sources.

Regulatory and mandate sources — FDA communications and state mandates related to reconstructive breast surgery and injectables

FDA communicationsFDA resources cited include Dermal Fillers approved by CDRH and two 2017 FDA safety communications warning against use of injectable silicone for body contouring and enhancement.

State mandates for reconstructive breast surgeryDistrict of Columbia, Maryland, and Virginia mandates requiring coverage for reconstructive breast surgery following mastectomy are referenced (DC Code §31-3832; Md. Insurance Code Ann. §15-815; Va. Code §38.2-3418.4).

Additional specialty referencesACOG committee opinions and ASPS/AAP position statements on reconstruction of abnormal appearance are included among other regulatory and professional sources.