Centene Cosmetic Reconstructive Coverage Update

Coverage Criteria

Medically necessary reconstructive procedures

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

Intent/Indications: Procedure intent meets one of: improve the function of an abnormal body part caused by illness, trauma, or a congenital defect after failure of conservative therapy (unless conservative therapy is not standard of care for the condition, or is contraindicated); scar or keloid revision/removal when unresponsive to conservative therapy and recurrently infected, unstable, friable, or associated with functional impairment or pain; skin tag removal when located in an area that affects eyesight or in an area of friction with documentation of repeated irritation and bleeding; post-mastectomy, medically necessary lumpectomy, or other medically necessary breast surgery resulting in significant asymmetry (includes breast reconstruction, nipple reconstruction, tattooing, and surgery on the contralateral breast to restore symmetry).

Conservative therapy requirement applies unless not standard of care or contraindicated.

Not medically necessary (cosmetic) procedures

The following procedures are considered not medically necessary when performed solely to improve normal appearance and self‑esteem:

Cosmetic exclusions: Procedures performed solely to improve normal appearance and self‑esteem are not medically necessary; includes, but is not limited to: excision of excessive skin; body contouring; breast augmentation; revision, removal, or replacement of cosmetic breast implants; liposuction (except for removal of lipoma as directed by clinical decision support criteria); removal of excess skin or body contouring after weight loss/bariatric surgery when solely cosmetic; abdominoplasty; facial augmentation; dermabrasion and skin rejuvenation; electrolysis/laser hair removal; tattooing (except for breast reconstruction post‑mastectomy); hair transplantation (unless to correct permanent hair loss from disease or injury); injectable fillers; mastopexy except when post‑mastectomy or to correct asymmetry after medically necessary breast surgery; circumcision revisions solely for appearance; correction of inverted nipples; and other listed cosmetic services.

List is illustrative, not exhaustive; see policy for full detail and Decision Support Criteria linkage.

General medical necessity

Policy applies when procedures meet documented medical necessity per Decision Support Criteria and related conditions:

General coverage logic: Procedures are covered when they meet Decision Support Criteria/medical necessity, including documented failure of conservative therapy when that is the standard of care and not contraindicated, and when the procedure addresses functional impairment (including areas affecting eyesight).

See the full policy for detailed, code‑specific criteria and any code‑level prior authorization requirements; conservative therapy requirement applies unless not standard of care or contraindicated.

The policy lists specific services that are considered not medically necessary (cosmetic) when performed solely to improve a patient’s normal appearance and self‑esteem. Examples include, but are not limited to: excision of excessive skin, body contouring, breast augmentation, liposuction (except for lipoma as directed by Decision Support Criteria), revision/removal/replacement of cosmetic breast implants, facial augmentation, abdominoplasty, skin rejuvenation and resurfacing, dermabrasion, electrolysis/laser hair removal, tattooing (except post‑mastectomy), hair transplantation (unless for disease/injury), injectable filler, and mastopexy (except when otherwise noted for post‑mastectomy or medically necessary breast surgery). These listed procedures are illustrative of the cosmetic exclusions in the policy; see the full policy for the complete listing and context.

Breast reconstruction performed for fibroadenomas or other benign lesions is specified in the policy as not medically necessary unless the procedure is determined to be medically necessary according to the applicable Decision Support Criteria. This exception requires evaluation against the policy’s clinical decision support framework to document medical necessity before coverage will be considered.

The policy states that cosmetic surgery performed solely to improve a patient’s normal appearance and self‑esteem is not medically necessary and is generally not a covered benefit. Providers should not expect coverage for procedures whose primary intent is aesthetic improvement rather than to address an abnormal structure or functional impairment.

Certain breast and body procedures such as mastopexy are listed as not medically necessary except in defined circumstances. Coverage may be considered when the procedure is performed post‑mastectomy, for a medically necessary lumpectomy, or for another medically necessary breast surgery that results in significant asymmetry. In all other situations where these procedures are purely cosmetic, they are excluded from coverage.

Coding

CPT Codes That Support Coverage Criteria (partial list)CPTCovered

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 unless listed elsewhere
11401	Excision, benign lesion including margins, except skin tag; trunk, arms or legs; excised diameter 0.6 to 1.0 cm
11402	Excision, benign lesion including margins, except skin tag; trunk, arms or legs; excised diameter 1.1 to 2.0 cm
11403	Excision, benign lesion including margins, except skin tag; excised diameter 2.1 to 3.0 cm
11404	Excision, benign lesion including margins, except skin tag; excised diameter 3.1 to 4.0 cm
11406	Excision, benign lesion including margins, except skin tag; excised diameter over 4.0 cm
11420	Excision, benign lesion including margins, except skin tag; scalp/neck/hands/feet/genitalia; excised diameter 0.5 cm or less

Additional CPT Codes referencedCPTCovered

11920	Tattooing; intradermal introduction of insoluble opaque pigments to correct
11921	Tattooing; intradermal introduction of insoluble opaque pigments to correct
11922	Tattooing; intradermal introduction of insoluble opaque pigments to correct color defects of skin
15773	Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth/neck/ears/orbits/genitalia/hands and/or feet; 25 cc or less injectate
15774	Grafting of autologous fat harvested by liposuction technique to face... each additional 25 cc injectate
15788	Chemical peel, facial; epidermal
15789	Chemical peel, facial; dermal
15792	Chemical peel, nonfacial; epidermal
15793	Chemical peel, nonfacial; dermal
15830	Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen infraumbilical panniculectomy

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Craniofacial reconstruction CPT codesCPT

21160	Reconstruction midface, LeFort II, with forehead advancement; requiring bone grafts
21172	Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts
21175	Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration
21179	Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic)
21180	Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft
21181	Reconstruction by contouring of benign tumor of cranial bones, extracranial
21182	Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following excision of benign tumor, with multiple autografts; total
21183	Reconstruction ... total area of bone grafting >40 sq cm but <80 sq cm
21184	Reconstruction ... total area of bone grafting >80 sq cm

Additional reconstructive and craniosynostosis CPT codesCPT

21230	Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)
21235	Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)
21255	Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage
21256	Reconstruction of orbit with osteotomies (extracranial) and with bone grafts
21260	Periorbital osteotomies for orbital hypertelorism; with bone grafts; extracranial approach
21261	Periorbital osteotomies for orbital hypertelorism; with bone grafts; combined intra-and extracranial approach
21263	Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement
21267	Orbital repositioning; periorbital osteotomies, unilateral, with bone grafts; extracranial approach
21268	Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and extracranial approach
21270	Malar augmentation, prosthetic material

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HCPCS / Injectable product codesHCPCS

G0429	Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) as a result of HAART
Q2026	Injection, Radiesse, 0.1 mL
Q2028	Injection, Sculptra, 0.5 mg

Lesion counts and excised diameter thresholds

11200 — lesion countRemoval of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions.

11201 — additional lesionsEach additional 10 lesions (or part thereof) reported in addition to primary procedure.

17110 — lesion count (destruction)Destruction of benign lesions other than skin tags; up to 14 lesions.

Excision diameter ranges (CPT 11401–11406)11401: trunk/arms/legs excised diameter 0.6–1.0 cm; 11402: 1.1–2.0 cm; 11403: 2.1–3.0 cm; 11404: 3.1–4.0 cm; 11406: >4.0 cm.

Bone grafting area thresholds

Provider Actions & Operational Notes

Prior Authorization

Prior Authorization / Coding Note

Prior authorization and correct coding may be required for certain reconstructive and cosmetic procedures. When requesting prior authorization, reference the CPT codes listed in this policy (inclusion of a code does not guarantee coverage). Verify plan-specific prior authorization requirements before scheduling.

Reference applicable CPT codes in the policy when submitting prior authorization requests.
Inclusion of a CPT code in the policy does not ensure coverage; coverage is subject to plan benefits and medical necessity determinations.

Documentation Required

Photographs May Be Requested

Photographs and other visual documentation may be requested to support medical necessity for reconstructive procedures (for example, to document functional impairment, recurrent infection, or pre-/post-operative asymmetry). Provide clear, dated clinical photographs when available and applicable.

Submit preoperative and postoperative photographs when clinically relevant and available.

Background

Reconstructive surgery is performed to correct abnormal body structures caused by congenital defects, developmental abnormalities, trauma, surgery, infection, tumors or disease, and is generally intended to improve function and may also restore appearance. The policy distinguishes reconstructive procedures that address a functional impairment (including areas that may affect eyesight) and that meet Decision Support Criteria — including documented failure of conservative therapy when appropriate — from purely cosmetic procedures that are not medically necessary.

Definitions

Functional impairment — definition and examples

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

Example — vision impactLesions or deformities located in areas that affect eyesight are considered under functional impairment criteria (policy references procedures addressing areas affecting eyesight).

Example — mobility/ADLsDecreased range of motion of a limb or hand that limits activities of daily living is considered functional impairment supporting reconstructive procedures.

Key reconstructive procedure code descriptions

21160Reconstruction midface, LeFort II with forehead advancement; requiring bone grafts.

21172 / 21175

OpenPayer

Cosmetic and Reconstructive Procedures

Coverage Criteria

Coding

Provider Actions & Operational Notes

Background

Definitions