CurrentCentenePolicy HNCA.CP.MP.169

Cosmetic and Reconstructive Surgery

Defines medical necessity criteria, exclusions, and coding guidance for cosmetic and reconstructive surgical procedures for Health Net of California members; affects providers submitting claims and prior authorization requests under Centene/Health Net CA benefits.

Policy Summary

PayerCentene

PolicyCosmetic and Reconstructive Surgery

Policy CodePolicy HNCA.CP.MP.169

Change TypeNo material change

Effective DateOct 4, 2023

Next Review DateOct 25, 2025

Key ActionSubmit prior authorization and documentation demonstrating reconstructive indications and appropriate CPT/ICD-10 coding when coverage depends on medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~70+procedure codes referenced

multiplediagnosis code groups

Californiastate references

I & IIcriteria sections

Coverage Criteria

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The policy lists an extensive set of procedures that are considered not medically necessary when performed solely to improve appearance or self‑esteem. Examples include, but are not limited to: elective rhinoplasty for external nasal deformity not due to trauma or disease; mastopexy (breast lift) unless otherwise specified; removal or revision of breast implants for non‑medical reasons; lipectomy/liposuction and excision of excessive skin (abdomen, thigh, arm, buttock, submental fat pad, etc.) unless otherwise specified; rhytidectomy (face lift) and other facial rejuvenation or resurfacing procedures (dermabrasion, chemical peels, laser resurfacing) for aging/wrinkles; hair transplants for male pattern baldness or age‑related thinning; most injectable filling materials (collagen, fat, other grafts) except when specifically indicated (e.g., HIV‑associated facial lipoatrophy); correction of inverted nipples, earlobe repair for cosmetic reasons, ear piercing, and many other listed cosmetic services such as buttock/thigh lifts, neck tucks, chin implants, and cryotherapy or chemical peels for acne scars.

Procedures performed purely to improve a patient's normal appearance or to address psychiatric or emotional distress related to appearance are considered not medically necessary. The policy explicitly enumerates many examples to guide determinations (e.g., cosmetic rhinoplasty, elective breast augmentation, cosmetic otoplasty for prominent ears without functional deficit, dermabrasion/chemical peel for cosmetic indications, elective hair transplantation for pattern baldness, and most injectable fillers and rejuvenation procedures) and indicates these services may be denied when no reconstructive/functional indication exists.

Coding and Diagnosis

Referenced Procedure CodesCPT | HCPCS

11200	Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions.
11300-11313	Shaving of epidermal or dermal lesions.
11400-	Excision of benign lesions.
11920	Tattooing, intradermal; 6.0 sq cm or less.
11921	Tattooing, intradermal; 6.1 to 20.0 sq cm.
11922	Tattooing, intradermal; each additional 20.0 sq cm.
11950	Subcutaneous injection or filling material; 1 cc or less.
11951	Subcutaneous injection; 1.1 cc to 5.0 cc.
11952	Subcutaneous injection; 5.1 cc to 10.0 cc.
11954	Subcutaneous injection; over 10.0 cc.

1–10 of 51

1/6

Supported Diagnosis CodesICD-10

L30.4	Erythema intertrigo.
M95.4	Acquired deformity of chest and rib.
Q16.0-Q16.9	Congenital malformations of ear causing impairment of hearing.
Q17.2	Microtia.
Q67.6	Pectus excavatum.
Q75.1	Crouzon's Syndrome.
Q75.4	Treacher-Collins Syndrome.
Q79.8	Poland syndrome.
Q82.5	Congenital non-neoplastic nevus.
D17.0-D17.9	Benign lipomatous neoplasm.

1–10 of 19

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Pulsed dye laser therapy failure — documented requirement before IPLS

RequirementDocumented evidence that pulsed dye laser therapy has been attempted and has failed prior to use of intense pulsed light systems (IPLS).

Supporting contextIPLS is considered a reconstructive option for port-wine stains only when pulsed dye laser therapy has failed.

Documentation to includeClinical notes describing prior pulsed dye laser treatments, dates, number of sessions, treatment response, and rationale for considering IPLS after failure.

Coding implicationRefer to procedure code group for vascular lesion treatments (e.g., 17106-17108) when documenting prior laser therapy and subsequent IPLS consideration.

Provider Actions & Prior Authorization

Prior Authorization

Prior Authorization & Benefit Administration

Prior authorization is required when coverage for reconstructive procedures is contingent on medical necessity and member benefit plans. Providers must obtain any prior authorization the member’s benefit plan requires before performing services. This clinical policy is a guide to medical necessity; actual prior authorization and benefit administration follow the member’s coverage documents and Health Plan administrative procedures.

Prior authorization implied where coverage is contingent on medical necessity and member benefits
Coverage decisions subject to member's evidence of coverage, plan exclusions, state and federal mandates

Billing Rule

Coding & Documentation Guidance

Include appropriate, specific CPT and ICD-10-CM codes that support the reconstructive indication when submitting prior authorization requests and claims. CPT codes referenced in this policy are informational only and do not guarantee coverage; providers should verify the most current coding guidance prior to claim submission.

Providers should document operative and diagnostic codes that clearly map to the reconstructive criteria listed in the policy (e.g., ICD-10 codes for congenital malformations, hemangioma, scar conditions)
Inclusion or exclusion of codes in this policy is not exhaustive — always reference current CPT/ICD-10 manuals

Documentation Required

Documentation & Reference Requirements

All clinical records, operative notes, diagnostic imaging, pathology, and other supporting documentation that substantiate the medical necessity of reconstructive procedures must be maintained and made available upon request. When conflicts arise between this clinical policy and state Medicaid provisions or Medicare NCDs/LCDs, the applicable state or federal requirement takes precedence. The Medical Director retains authority to deny services deemed cosmetic and not medically necessary.

Retain and submit documentation demonstrating functional impairment, symptomatic lesions, or other reconstructive indications
Review applicable NCDs/LCDs and state Medicaid manuals prior to applying policy criteria
Medical Director may deny coverage for procedures considered cosmetic only

Background

Reconstructive surgery is intended to correct abnormal structures caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease with the primary goals of improving or restoring function and, when appropriate, creating a more normal appearance. Typical reconstructive indications include repair of congenital ear deformities (microtia/anotia) with functional hearing considerations, treatment of severe burns or traumatic deformities, excision of lesions or implants causing functional impairment or medical complications, and reconstruction after mastectomy. Providers should distinguish these functional or disease‑related indications from cosmetic procedures that address normal anatomy solely for appearance.

Definitions

Reconstructive surgery — definition

DefinitionSurgery to correct abnormal structures of the body caused by congenital defects, developmental abnormalities, previous or concurrent surgeries, trauma, infection, tumors or disease, performed primarily to improve function and may or may not restore normal appearance.

Functional impairment examplesDecreased range of motion, diminished eyesight or hearing, or other limitations impacting activities of daily living.

Policy relevanceReconstructive indications in the policy are covered when any listed criteria demonstrating functional deficit or disease-related deformity are met.

Cosmetic surgery — definition

DefinitionSurgery performed to reshape normal structures of the body to improve appearance and self-esteem; generally not considered medically necessary.

Examples excludedProcedures performed purely to enhance appearance (e.g., rhytidectomy, cosmetic rhinoplasty, mastopexy) are listed as not medically necessary unless a reconstructive indication exists.

Denial riskServices determined to be cosmetic in nature may be denied by the Medical Director per policy.

Keloids and hypertrophic scars — definition / literature pointers

Topic pointerKeloids and hypertrophic scars: see UpToDate and cited literature for detailed management guidance (references include Goldstein BG; Ogawa R. UpToDate entries).

Policy referencesPolicy notes repair/revision of scars (including keloids) originating from covered procedures when associated with significant symptoms not responsive to conservative therapy; low-dose radiation may be an adjunct following excision when criteria met.

Selected citationsGoldstein BG, Goldstein AO. Keloids and hypertrophic scars. UpToDate; Ogawa R. Keloids and hypertrophic scars. UpToDate (listed in policy references).