CurrentCentenePolicy HNCA.CPMP.169

Clinical Policy: Cosmetic and Reconstructive Surgery

Defines medical necessity criteria for reconstructive surgery and lists procedures considered cosmetic (not medically necessary) versus reconstructive (medically necessary) with supporting diagnosis codes and procedure code examples. Applies subject to member benefits, state/federal mandates, and Medical Director discretion.

Policy Summary

PayerCentene

PolicyClinical Policy: Cosmetic and Reconstructive Surgery

Policy CodePolicy HNCA.CPMP.169

Change TypeAnnual review / clarifications

Effective Date

Next Review Date

Key ActionObtain prior authorization when coverage is uncertain and document functional deficiency, significant symptoms, or failure of conservative treatments to support reconstructive surgery claims.

POLICY UPDATE CHANGES

Policy adopted from Health Net NMP169 and multiple annual reviews noted; recent annual review 10/24 indicates no clinical policy changes.

Added language to refer to California reconstructive surgery mandates and noted exceptions for gender dysphoria treatment.

Nasal surgery and pectus excavatum / Nuss procedure were removed from medically necessary section in 11/19 because they have InterQual criteria.

Added use of facial dermal injections/autologous fat transfers for facial lipodystrophy (W) in 05/20.

~40Example CPT/ICD codes listed

2Primary coverage categories

Referenced LCD (L39051)

Coverage Summary

Overview: This policy (HNCA.CPMP.169) defines medical necessity criteria distinguishing reconstructive surgery from cosmetic surgery and applies subject to member benefits, state and federal mandates, and plan-level administrative policies. The policy cites California reconstructive surgery mandates and other statutory requirements. The Medical Director has final decision authority for services deemed cosmetic and not medically necessary, and prior authorization should be obtained when coverage is uncertain. Coverage stance: mixed (some procedures are medically necessary as reconstructive; others are not medically necessary as cosmetic).

Policy identifiers and review: Policy Number: HNCA.CPMP.169. Last review: 10/24 (annual review noted; recent revision history documents prior updates and additions).

Policy snapshot

Primary categoriesReconstructive vs Cosmetic

Policy statusCURRENT

Last review2024-10-24

Referenced LCD1 (L39051: Cosmetic and Reconstructive Surgery)

Example CPT/ICD code counts~40 example CPT/ICD codes listed

Medically Necessary (Reconstructive) Surgery

It is the policy of Health Net of California that reconstructive surgery is medically necessary for any of the following indications:

Medically Necessary (Reconstructive) Surgery - Top Level

Congenital/functional indications
- Surgery to correct congenital defects that cause significant functional deficiencies or challenges of any body part, developmental abnormalities, degeneration defects, trauma, infections, tumors or disease
Facial surgery for severe disfigurement: Facial surgery to correct congenital, acquired, traumatic, or developmental anomalies that may not result in functional impairment but are so severely disfiguring as to merit corrective surgery (examples: craniofacial anomalies associated with Crouzon's Syndrome and Treacher-Collins Syndrome)

Not Medically Necessary (Cosmetic) Surgery

It is the policy of Health Net of California that cosmetic surgery is not medically necessary and generally not a covered benefit when performed to improve a patient's normal appearance and self-esteem. Examples include (but are not limited to):

Not Medically Necessary (Cosmetic) Surgery - Top Level

Purely cosmetic procedures: Cosmetic surgery performed purely for the purpose of enhancing one's appearance and/or expenses incurred in connection with such surgery
Psychiatric indications: Cosmetic surgery performed to treat psychiatric or emotional distress, problems or disorders
Flesh color tattooing for vascular birthmarks: Flesh color tattooing for treatment of port wine stains, hemangiomas or birthmarks

Coding (examples)

Example CPT codes referenced (informational; not all-inclusive)CPT

11200	Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions
11300-11313	Shaving of epidermal or dermal lesions (range included)
11400	Excision of benign lesions (general series)
11920	Tattooing, intradermal, introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less
11921	Tattooing, intradermal, introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm or portion thereof (list separately in addition to code for primary procedure)
11922	Tattooing, intradermal, introduction of insoluble opaque pigments to correct color defects of skin; each additional 20.0 sq cm
11950	Subcutaneous injection or filling material (e.g., collagen); 1 cc or less
11951	Subcutaneous injection or filling material (e.g., collagen); 1.1 cc to 5.0 cc
11952	Subcutaneous injection or filling material (e.g., collagen); 5.1 cc to 10.0 cc
11954	Subcutaneous injection or filling material (e.g., collagen); over 10.0 cc

1–10 of 18

1/2

HCPCS referenced (informational; not all-inclusive)HCPCS

No codes listed

ICD-10-CM diagnosis codes that support coverage criteriaICD-10Covered

Q17.0	Congenital malformation of external ear
D21.9	Benign neoplasm of connective and other soft tissue, unspecified
L91.0	Keloid
I83.90	Varicose veins of unspecified lower extremity with unspecified complications

Codes listed are informational only; inclusion or exclusion does not guarantee coverage. Providers should reference up-to-date coding guidance.

Provider Actions

Prior Authorization

Medical Director discretion / Prior authorization for cosmetic determinations

The Medical Director has final decision authority for coverage determinations for services deemed cosmetic and not medically necessary; providers should obtain prior authorization per plan procedures when coverage is uncertain.

Documentation Required

Documentation of functional impairment or symptoms required for reconstructive coverage

Providers must document evidence of functional deficiency, significant symptoms (e.g., bleeding, pain, ulceration), failure of conservative treatments (when applicable), or interference with activities of daily living to support reconstructive surgery claims.

Evidence of functional deficiency or significant symptoms (bleeding, pain, ulceration) — see hemangioma criteria
Documentation of failure of conservative treatments when applicable

Background & Evidence

Background: The policy distinguishes reconstructive surgery—performed to correct or repair abnormal structures caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease to improve function or create a normal appearance—from cosmetic surgery—performed to reshape normal structures to improve appearance and self-esteem and generally not considered medically necessary. Applicability is always subject to member benefits, state and federal mandates (notably California Health and Safety Code provisions requiring coverage for reconstructive surgery and breast reconstruction incident to mastectomy), and plan administrative policies.

Changes and exceptions: The policy history documents additions clarifying California reconstructive mandates and notes exceptions related to gender dysphoria treatment; specific procedure inclusions and exclusions have been updated over time per the revision log.

Medical Director discretion: The Medical Director retains final authority for coverage determinations for services deemed cosmetic and not medically necessary; providers are expected to document functional deficits, significant symptoms, or failure of conservative treatments when seeking reconstructive coverage.

Source	Notes
Referenced statutory requirement
California Health and Safety Code 1367.63 and 1367.6 cited as requiring coverage for reconstructive surgery and breast reconstruction incident to mastectomy
Referenced clinical sources
ASPS position papers, NICE guidance, Hayes brief, UpToDate chapters cited in references

Medicare Determinations

Name	Number	Type	Effective Date
Cosmetic and Reconstructive Surgery
L39051
LCD

Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome
250.5
NCD

Definitions

Reconstructive surgery: Surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to improve function or to create a normal appearance, to the extent possible.

Cosmetic surgery: Surgery performed to reshape normal structures of the body to improve appearance and self-esteem; generally not medically necessary and not covered except as noted under specific exceptions (for example, certain gender-affirming procedures or statutorily required reconstructive care).

Revision History

12/16clarified

Policy adopted from Health Net NMP169 and multiple annual reviews noted; recent annual review 10/24 indicates no clinical policy changes. Detail: Revision log lists prior additions and removals in past years; latest entries 'Annual review no changes' for 10/24.

11/18added

Added language to refer to California reconstructive surgery mandates and noted exceptions for gender dysphoria treatment. Detail: Change occurred in 11/18; reflected in policy background and scope.

11/19removed

Nasal surgery and pectus excavatum / Nuss procedure were removed from medically necessary section in 11/19 because they have InterQual criteria. Detail: Historical coding/coverage change documented in revision log.

Policy Summary

PayerCentene

PolicyClinical Policy: Cosmetic and Reconstructive Surgery

Policy CodePolicy HNCA.CPMP.169

Change TypeAnnual review / clarifications

Effective Date

Next Review Date

On This Page

Surgery in connection with treatment of severe burns

Therapeutic procedures with cosmetic effect: Surgery for therapeutic purposes which coincidentally also serve some cosmetic purpose

Prosthetic insertion/injection: Insertion or injection of prosthetic material for significant deformity from disease or trauma

Pulsed dye laser therapy for proliferative vascular disorders such as congenital port wine stains of the face or neck

Intense pulsed light after laser failure: Use of intense pulsed light sources (e.g., PhotoDerm VL) for treatment of congenital port wine stains when there is documented failure of dye laser therapy

Surgical treatment of congenital hemangiomas

Hemangioma criteria
- Interfering with function: The hemangioma is interfering with functionality of the nose, eyes, ears, lips or larynx
- Symptomatic hemangioma: The hemangioma is symptomatic (e.g., bleeding, painful, ulcerated, recurrent infection)
- Kasabach-Merritt association: The hemangioma is associated with Kasabach-Merritt Syndrome
- Pedunculated hemangioma: The hemangioma is pedunculated

Tattoo excision: Excision/treatment of tattoos of traumatic or therapeutic origins

Keloid radiation adjunct: Low-dose radiation (superficial or interstitial) as adjunctive therapy immediately following excisional surgery (within 7 days) in the treatment of keloids when criteria for keloid removal are met

Scar repair/revision: Repair/revision of scars, including keloids, originating from a covered surgical or therapeutic procedure or an accidental injury that are associated with significant symptoms (pain, burning, itching) not responsive to nonnarcotic analgesics/steroid injections, that interfere with normal bodily function (e.g., joint movement), or are unstable with history of intermittent breakdown

Testicular prostheses for replacement of congenitally absent testes, or testes lost due to disease, injury, or surgery

Skin tag removal when located in an area of friction with documentation of repeated irritation and bleeding

Lipoma excision: Excision of lipoma(s) when located in areas of repeated touch or pressure with documentation of tenderness and/or inhibition of activities of daily living

External facial prosthesis when loss or absence of facial tissue due to disease, trauma, surgery, or congenital defect, regardless of restoration of function

Facial implants for deformity: Chin, cheek, or jaw reshaping (facial implants or soft tissue augmentation) for deformities of the maxilla or mandible resulting from trauma or disease (distinct from orthognathic surgery)

Ear reconstruction for hearing: Reconstruction for shaped or absent external ears (e.g., anotia) with functional deficiencies when performed to improve hearing by directing sound into the ear canal

Punch hair transplant may be considered reconstructive when performed to correct permanent hair loss clearly caused by disease or injury (examples: eyebrow replacement following burn injury or tumor removal)

Breast reconstruction post-mastectomy: Post-mastectomy or post-significant lumpectomy resulting in asymmetry: breast reconstruction, including nipple reconstruction, tattooing and surgery on contralateral breast to restore symmetry

Breast implant for Poland's syndrome (congenital absence of breast)

Breast implant complications: Removal of a breast implant, periprosthetic capsulotomy or capsulectomy for mechanical complications of breast prosthesis such as rupture, extrusion, painful capsular contracture with disfigurement, inflammatory reaction to implant, siliconoma, granuloma, or interference with diagnosis of breast cancer

Repair of breast asymmetry due to trauma

Facial dermal injections for FLS: Use of FDA-approved facial dermal injections (e.g., Sculptra, Radiesse) or autologous fat transfers for HIV-associated wasting / facial lipodystrophy syndrome (FLS)

Dermabrasion/peels etc: Dermabrasion, chemical peel, liquid nitrogen, skin grafting, dry ice or CO2 snow unless otherwise specified

Intense pulsed light for vascular lesions: Intense pulsed light treatment of proliferative vascular disorders such as port wine stains, hemangiomas, spider angiomas, cherry angiomas and facial telangiectasias (when not otherwise specified as reconstructive/medically necessary)

Rhinoplasty for non-traumatic deformity: Rhinoplasty for external nasal deformity not due to trauma or disease

Septoplasty for appearance only: Septoplasty performed solely to improve appearance in absence of signs/symptoms of functional respiratory abnormalities

Mastopexy (breast lift) to treat sagging of the breast unless otherwise specified

Moon face correction: Surgery to correct 'moon face' developed as side effect of cortisone therapy

Removal/revision non-medical: Removal or revision of a breast implant for non-medical reasons

Otoplasty cosmetic: Otoplasty (ear pinning) for prominent/protruding ears without functional impairment

Injection of filling material cosmetic: Injection of any filling material (collagen, fat, autologous or foreign materials) unless treatment for facial lipodystrophy

Hair transplant cosmetic: Hair transplant for male pattern baldness (alopecia) or age-related thinning in women

Rhytidectomy (face lift) for aging skin

Excision of excess skin/fat: Excision of excessive skin or submental fat (arm, thigh, hip, buttock, forearm, hand, leg) unless otherwise specified

Lipectomy/liposuction: Removal of fatty tissue by lipectomy (suction-assisted liposuction, lipoplasty) unless otherwise specified

Electrolysis/laser hair removal: Electrolysis or laser hair removal unless specified (e.g., gender-affirming procedures)

Sclerosing veins: Sclerosing of spider veins and/or telangiectasis

Inverted nipples cosmetic: Correction of inverted nipples (cosmetic)

Glabellar frown lines: Excision/correction of glabellar frown lines

Buttock or thigh lifts

Facial rejuvenation/collagen: Facial rejuvenation/plumping/collagen or fat injections (cosmetic indications)

Chin implants cosmetic: Chin implants to improve appearance

Cryotherapy for acne

Chemical peels cosmetic: Chemical peels for photoaged skin, wrinkles, or acne scarring (cosmetic)

Dermabrasion cosmetic: Dermabrasion for wrinkling, pigmentation or severe acne scarring (cosmetic)

Laser resurfacing cosmetic: Laser resurfacing for wrinkling, aging skin or telangiectasias from rosacea

Injection prosthetic cosmetic: Insertion or injection of prosthetic material to replace absent adipose tissue (cosmetic)

Breast augmentation: Augmentation mammoplasty (breast augmentation) of small but otherwise normal breasts unless part of gender-affirming surgery

Phalloplasty cosmetic: Phalloplasty (penis enlargement)

Diastasis recti repair cosmetic: Diastasis recti repair in absence of true midline hernia without evidence of current or potential incarceration, volvulus, or strangulation of bowel

Decorative tattoos: Excision/treatment of decorative tattoos

Vaccination scars revision: Repair/revision of vaccination scars

Labia minor reduction: Reduction of labia minor (cosmetic)

Collagen implant cosmetic: Collagen implant (e.g., Zyderm) for cosmetic indications

Earlobe repair cosmetic: Earlobe repair to close a stretched pierced hole (cosmetic)

Child Downs appearance change: Surgery to change appearance of a child with Down Syndrome

Vestibuloplasty cosmetic: Vestibuloplasty (cosmetic indications)

Vermilionectomy cosmetic: Vermilionectomy (lip shave) with mucosal advancement (cosmetic indications)

Evidence that condition interferes with activities of daily living or normal bodily function (e.g., joint movement, hearing, vision)

Billing Rule

Codes included are informational only

CPT/HCPCS codes listed are for informational purposes only; inclusion or exclusion does not guarantee coverage and providers should reference up-to-date coding guidance when submitting claims.

05/20added

Added use of facial dermal injections/autologous fat transfers for facial lipodystrophy (W). Detail: Reflects inclusion for HIV-associated wasting/facial lipodystrophy syndrome.

10/24clarifiedLatest

Annual review no changes. Detail: Revision log lists prior additions and removals in past years; latest entries 'Annual review no changes' for 10/24.