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 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.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.