CurrentCentenePolicy CP.MP.31

Cosmetic and Reconstructive Procedures

Defines medical necessity criteria for reconstructive procedures and lists procedures considered cosmetic and therefore not medically necessary; provides supporting CPT/HCPCS codes and policy history. Applies to Centene-affiliated health plans (non-Medicare specific guidance noted).

Policy Summary

PayerCentene

PolicyCosmetic and Reconstructive Procedures

Policy CodePolicy CP.MP.31

Change TypeClarified / Added / Revised (see changes)

Effective Date

Next Review Date

Key ActionWhen invoking medical necessity based on functional improvement after failure of conservative therapy, document conservative therapy attempts unless conservative therapy is not standard of care or is contraindicated; photograph documentation may be requested, if applicable.

SourceLink

POLICY UPDATE CHANGES

Reformatted Criteria and moved HIV/facial lipodystrophy specifics for clarity; removed prior requirement for medical records with photographs (converted to a note).

Added HCPCS codes G0429, Q2026, Q2028 for dermal filler injections for HIV-associated facial lipodystrophy syndrome.

Clarified failure of conservative therapy clause to allow exceptions when conservative therapy is not standard of care or contraindicated.

Added numerous craniofacial and reconstruction CPT codes from a retired Craniofacial Surgery policy.

~120CPT/HCPCS codes referenced

2Primary coverage intent categories

Coverage Summary

This policy distinguishes reconstructive procedures—performed on abnormal body structures to improve function (and sometimes appearance) due to congenital defects, trauma, surgery, infection, tumors or disease—from cosmetic procedures—performed to improve normal appearance and self‑esteem and generally considered not medically necessary. It applies to Centene‑affiliated health plans and takes a mixed coverage stance: reconstructive procedures meeting the stated medical necessity criteria are covered, cosmetic procedures are generally not covered, and there is a specific covered exception for use of FDA‑approved facial dermal injections (e.g., Sculptra, Radiesse) or autologous fat transfers for HIV‑associated facial lipodystrophy syndrome (LDS).

Policy metadata

Policy numberCP.MP.31

SubjectCosmetic and Reconstructive Procedures

StatusCURRENT

Last review date2024-08-25

Medicare LCD referenceL33428 - Local coverage determination: cosmetic and reconstructive surgery

Medical‑Necessity Criteria

Medically Necessary Reconstruction

Reconstructive procedures are considered medically necessary when meeting ONE of the following intents:

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Coding

CPT Codes Supporting Coverage CriteriaCPTCovered

11200	Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions.
11201	Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof.
11400	Excision, benign lesion including margins, except skin tag, trunk/arms/legs; excised diameter 0.5 cm or less.
11401	Excision, benign lesion trunk/arms/legs; 0.6 to 1.0 cm.
11402	Excision, benign lesion trunk/arms/legs; 1.1 to 2.0 cm.
11403	Excision, benign lesion trunk/arms/legs; 2.1 to 3.0 cm.
11404	Excision, benign lesion trunk/arms/legs; 3.1 to 4.0 cm.
11406	Excision, benign lesion trunk/arms/legs; over 4.0 cm.
11420	Excision, benign lesion scalp/neck/hands/feet/genitalia; 0.5 cm or less.
11421	Excision, benign lesion scalp/neck/...; 0.6 to 1.0 cm.

1–10 of 110

1/11

HCPCS Codes Supporting Coverage Criteria (HIV-associated LDS fillers)HCPCSCovered

G0429	Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) as a result of highly active antiretroviral therapy.
Q2026	Injection, Radiesse, 0.1 ml.
Q2028	Injection, Sculptra, 0.5 mg.

Provider Actions

Documentation Required

Document conservative therapy and functional impairment

When invoking medical necessity based on functional improvement after failure of conservative therapy, document conservative therapy attempts unless conservative therapy is not standard of care or is contraindicated; photograph documentation may be requested, if applicable.

Photographs may be requested, if applicable.

Documentation Required

Document skin tag symptoms

For skin tag removal coverage, document location (area affecting eyesight or area of friction) and repeated irritation and bleeding.

11200
11201

Background

Reconstructive surgery is performed on abnormal body structures caused by congenital defects, developmental abnormalities, trauma, surgery, infection, tumors or disease and is generally intended to improve function of a body part and may also restore appearance. Cosmetic surgery is performed to reshape normal structures to improve appearance and self‑esteem and is generally not medically necessary.

Functional impairment: a health condition in which the normal function of a part of the body or organ system is less than age‑appropriate at full capacity (for example, decreased range of motion, diminished eyesight or hearing) that variably impacts activities of daily living.

Medicare Determinations

Determination	Number	Effective/Revised Date
Local coverage determination: cosmetic and reconstructive surgery	L33428	2015-10-01 (revised 2021-07-29)

Revision History

08/25clarifiedLatest

Reformatted Criteria and moved HIV/facial lipodystrophy specifics for clarity; removed prior requirement for medical records with photographs (converted to a note).

08/24clarified

Reformatted Criteria and moved HIV/facial lipodystrophy specifics for clarity; removed prior requirement for medical records with photographs (converted to a note).

10/22added

Added poly-L-lactic acid and calcium hydroxylapatite microspheres to criteria for HIV-associated facial lipodystrophy syndrome (LDS).