CurrentColorado Rocky Mountain Health PlansPolicy MMP022.15

Cosmetic and Reconstructive Procedures – Medicare Advantage Medical Policy

Medicare Advantage medical policy clarifying coverage distinctions between cosmetic and reconstructive surgical procedures, listing procedure-specific coverage rationales, applicable CMS LCD/LCA references, and CPT/HCPCS codes that may be cosmetic or reconstructive or are considered cosmetic (not covered).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCosmetic and Reconstructive Procedures – Medicare Advantage Medical Policy

Policy CodePolicy MMP022.15

Change TypeCoding and coverage clarifications

Effective DateJun 1, 2026

Next Review Date

Key ActionWhere applicable, comply with Local Coverage Determinations/Local Coverage Articles and retain documentation (e.g., preoperative photographs, symptom duration, weight stability) to support reconstructive indications.

SourceLink

POLICY UPDATE CHANGES

Added language that Medicare does not have an NCD for rib graft and that LCDs/LCAs must be followed where applicable.

Removed CPT code 15819 from Cosmetic and Non-Covered codes.

Added multiple ICD-10 diagnosis codes for Abdominal Lipectomy/Panniculectomy (L98.431-L98.439) and facial/maxillofacial reconstruction (H05.831-H05.833).

Updated supporting information sections (Clinical Evidence, FDA, References) to reflect current information.

~50CPT/HCPCS codes listed

multipleReferenced LCDs/LCAs/MACs

Mixed

Evidence direction for concurrent panniculectomy

LimitedHigh-quality RCT evidence across topics

06/01/2026Policy revision date

Coverage Summary

This Medicare Advantage policy clarifies the coverage distinction between cosmetic and reconstructive surgical procedures consistent with Medicare statutory authority. It references Social Security Act §1862(a)(1)(A) and the CMS Medicare Benefit Policy Manual, Chapter 16 §120 for the exclusion of cosmetic surgery and the circumstances in which reconstruction may be covered.

Where no applicable CMS National Coverage Determination (NCD) exists for a procedure, this policy directs reliance on applicable Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) and, when specified, InterQual criteria to determine coverage. The policy lists multiple LCDs/LCAs and instructs review of the Medicare Coverage Database for contractor-specific guidance.

The policy notes that for states or territories without an applicable LCD/LCA, the CMS definition of cosmetic and reconstructive surgery (as set out in the policy Overview) should be used to guide coverage determinations.

Benefit coverage is determined by the member-specific benefit plan document; in the event of a conflict between this policy and a member's benefit document, the member-specific benefit plan document supersedes this policy.

Effective date: June 1, 2026. Last review / committee approval date: May 13, 2026.

Thresholds / Requirements

Symptom duration>= 3 months (symptoms present and refractory to usual standard medical therapy)

Stable weight rules>= 6 months stable weight generally; if post-bariatric, wait >= 18 months after bariatric surgery and weight stable for most recent 6 months

Pannus gradingGrade 1 = pannus reaching mons pubis; Grade 5 = pannus extending to/past knees

Follow-up durations in studiesFollow-up 1-36 months (Rasador et al. 2024); mean 17.8 ±7.7 months (Sosin et al. 2020)

Medical-Necessity Criteria

Reconstructive versus cosmetic surgery is determined by whether the procedure is performed to improve function or to repair abnormal structures caused by congenital defects, developmental abnormalities, trauma, tumors, or disease. Cosmetic procedures performed to improve appearance or self‑esteem are not covered unless they meet reconstructive criteria or are required for prompt repair after accidental injury. Refer to Section 1862(a)(1)(A) of the Social Security Act and the Medicare Benefit Policy Manual, Chapter 16, §120.

ALL of the following

Procedure is performed to correct abnormal structures caused by congenital defects, developmental abnormalities, trauma, tumors, or disease (reconstructive indication).
Primary purpose of the procedure is to improve function or to restore normal appearance secondary to a covered medical condition or injury, not solely to improve cosmetic appearance.
When applicable, documentation includes medical history, physical exam findings, and photographs to support functional impairment or deformity rather than cosmetic concern.

Coding

Procedure Codes That May Be Cosmetic or Reconstructive (reference list)CPT

15830	Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
15847	Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)
14000	Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less
14001	Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm
14020	Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less
14021	Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm
14040	Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less
14041	Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm
14060	Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less
14061	Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm

1–10 of 83

1/9

Procedure Codes Considered Cosmetic (Not Covered)CPT|HCPCSNot Covered

11960	Insertion of tissue expander(s) for other than breast, including subsequent expansion (may be cosmetic; review required)
11950	Subcutaneous injection of filling material; 1 cc or less (cosmetic, not covered)
11951	Subcutaneous injection of filling material; 1.1 to 5.0 cc (cosmetic, not covered)
11952	Subcutaneous injection of filling material; 5.1 to 10.0 cc (cosmetic, not covered)
11954	Subcutaneous injection of filling material; over 10.0 cc (cosmetic, not covered)
15786	Abrasion; single lesion (e.g., keratosis, scar) (cosmetic, not covered)
15787	Abrasion; each additional 4 lesions or less (cosmetic, not covered)
15824	Rhytidectomy; forehead (cosmetic, not covered)
15825	Rhytidectomy; neck with platysmal tightening (cosmetic, not covered)
15826	Rhytidectomy; glabellar frown lines (cosmetic, not covered)

1–10 of 17

1/2

Referenced LCDs / LCAs / MACsmixed

L39506	LCD - Cosmetic and Reconstructive Surgery
A59299	LCA - Billing and Coding: Cosmetic and Reconstructive Surgery
L38914	LCD - Cosmetic and Reconstructive Surgery (CGS)
A58573	LCA - Billing and Coding: Cosmetic and Reconstructive Surgery (First Coast)
L35090	LCD - Cosmetic and Reconstructive Surgery (Novitas)
A56587	LCA - Billing and Coding: Cosmetic and Reconstructive Surgery (Novitas)
L33428	LCD - Cosmetic and Reconstructive Surgery (Palmetto)
A56658	LCA - Billing and Coding: Cosmetic and Reconstructive Surgery (Palmetto)
L39051	LCD - Cosmetic and Reconstructive Surgery (WPS)
A58774	LCA - Billing and Coding: Cosmetic and Reconstructive Surgery (WPS)

1–10 of 15

1/2

CPT Codes — Cosmetic and Non-Covered (removed)CPTNot Covered

15819

Removed from Cosmetic and Non-Covered list (no longer listed as cosmetic/non-covered per 06/01/2026 revision)

CPT Codes — Facial and Maxillofacial Reconstruction (referenced)CPT

21120	Facial and maxillofacial reconstruction — referenced in diagnosis code additions
21121	Facial and maxillofacial reconstruction
21122	Facial and maxillofacial reconstruction
21123	Facial and maxillofacial reconstruction
21125	Facial and maxillofacial reconstruction
21127	Facial and maxillofacial reconstruction
21137	Facial and maxillofacial reconstruction
21138	Facial and maxillofacial reconstruction
21139	Facial and maxillofacial reconstruction
21172	Facial and maxillofacial reconstruction

1–10 of 30

1/3

Diagnosis Codes — Abdominal Lipectomy/Panniculectomy additionsICD-10

L98.431	Added for CPT 15830/15847
L98.432	Added for CPT 15830/15847
L98.433	Added for CPT 15830/15847
L98.434	Added for CPT 15830/15847
L98.435	Added for CPT 15830/15847
L98.436	Added for CPT 15830/15847
L98.438	Added for CPT 15830/15847
L98.439	Added for CPT 15830/15847

Diagnosis Codes — Facial and Maxillofacial Reconstruction additionsICD-10

H05.831	Added for facial/maxillofacial CPT codes
H05.832	Added for facial/maxillofacial CPT codes
H05.833	Added for facial/maxillofacial CPT codes
M27.3	Deleted Dec. 31, 2024 (not to be used)

Always Cosmetic — Diagnosis additions/changesICD-10Not Covered

Z40.89	Added to 'Always Cosmetic' list
Z40.8	Deleted Sep. 30, 2025 (notation)

Provider Actions & Documentation Requirements

Documentation Required

Document and retain clinical evidence supporting medical necessity for reconstructive procedures. Include symptom duration (e.g., symptoms present ≥3 months for panniculectomy) and objective assessment of functional impairment (e.g., inability to walk normally, chronic pain, recurrent intertrigo or ulceration). Maintain photographic documentation (preoperative photos showing pannus extending below the symphysis pubis) to support panniculectomy candidacy and supply upon request.

Document symptom onset and conservative therapy trials and responses (e.g., topical/systemic treatment for intertrigo/dermatitis)
If post–significant weight loss, document duration of stable weight (≥6 months); if weight loss due to bariatric surgery, document interval of ≥18 months post‑bariatric surgery and stable weight for the most recent 6 months

Prior Authorization

Prior Authorization / Coverage Verification

Background and Evidence Summary

Medicare statutory references informing this policy include Section 1862(a)(1)(A) of the Social Security Act, which excludes payment for items or services that are not reasonable and necessary, and the CMS Medicare Benefit Policy Manual, Chapter 16 §120 (Cosmetic Surgery), which describes when cosmetic surgery is excluded and the exceptions for repair after accidental injury or for malformed body members.

When CMS National Coverage Determinations (NCDs) do not provide coverage criteria for a given procedure, the policy requires reliance on applicable Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs) and, where cited, InterQual® criteria to determine medical necessity and coverage. The policy includes a table of referenced LCDs/LCAs and instructs users to consult the Medicare Coverage Database for contractor-specific guidance.

Regarding rib grafts, the policy explicitly states that Medicare does not have an NCD for rib graft; LCDs/LCAs exist for rib graft and compliance with those local policies is required where applicable. For states/territories with no LCDs/LCAs for rib graft, the CMS definition of cosmetic and reconstructive surgery in the policy Overview should be used to determine coverage.

Panniculectomy / Abdominal Lipectomy Evidence-informed considerations

Evidence-informed considerations and guideline statements relevant to panniculectomy decisions (summarized):

ASPS guidance: ASPS (2019): Abdominoplasty or panniculectomy performed solely to enhance appearance in absence of functional abnormalities is cosmetic (not compensable). ASPS (2017): panniculectomy may be considered reconstructive when correcting structural abdominal wall defects, improving skin health under pannus, or improving chronic low back pain; weight stability recommended (non-bariatric 2-6 months; post-bariatric 12-18 months).

Medicare Determinations / LCDs & LCAs

Type (NCD/LCD/LCA)	Number	Name	Effective Date
NCD	140.2	Breast Reconstruction Following Mastectomy
LCD	L39506	Cosmetic and Reconstructive Surgery
LCA	A59299	Billing and Coding: Cosmetic and Reconstructive Surgery
LCD	L38914	Cosmetic and Reconstructive Surgery
LCA	A58573	Billing and Coding: Cosmetic and Reconstructive Surgery
LCD	L35163	Plastic Surgery
LCA	A57221	Billing and Coding: Plastic Surgery
LCD	L35090	Cosmetic and Reconstructive Surgery
LCA	A56587	Billing and Coding: Cosmetic and Reconstructive Surgery
LCD	L33428	Cosmetic and Reconstructive Surgery
LCA	A56658	Billing and Coding: Cosmetic and Reconstructive Surgery
LCD	L39051	Cosmetic and Reconstructive Surgery
LCA	A58774	Billing and Coding: Cosmetic and Reconstructive Surgery
LCD	L37020	Plastic Surgery (Retired)	Retired 10/16/2025
NCD		Rib Graft	No NCD exists for rib graft per policy revision 06/01/2026

Revision History

2026-06-01revisionLatest

Policy revision effective 06/01/2026: added language noting Medicare does not have an NCD for rib graft and that LCDs/LCAs must be followed where applicable; added instruction to refer to the CMS definition of cosmetic and reconstructive surgery for states/territories with no LCDs/LCAs; removed CPT code 15819 from Cosmetic and Non-Covered codes; added multiple ICD-10 diagnosis codes for abdominal lipectomy/panniculectomy and facial/maxillofacial reconstruction; added Z40.89 and noted deletions of M27.3 and Z40.8. Archived prior policy version MMP022.14.

2025-10-16policy_history

LCD L37020 Plastic Surgery retired (noted in CMS related documents and LCD tables).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCosmetic and Reconstructive Procedures – Medicare Advantage Medical Policy

Policy CodePolicy MMP022.15

Change TypeCoding and coverage clarifications

Effective DateJun 1, 2026

Next Review Date

SourceLink

On This Page

Abdominal Lipectomy/Panniculectomy - Coverage when LCDs/LCAs absent

Pannus hangs below the level of the symphysis pubis and causes at least one of: inability to walk normally due to pannus size; chronic pain; ulceration created by the abdominal skin fold; or intertrigo/dermatitis.
Symptoms have been present for at least 3 months and are refractory to usual standard medical therapy.
Preoperative photographs may be required to support medical necessity and should be provided upon request.
Operational: maintain photo documentation in chart.
If procedure follows significant weight loss
- Evidence the individual has maintained a stable weight for at least 6 months following weight loss.
- If weight loss resulted from bariatric surgery, procedure is deferred until at least 18 months after bariatric surgery and only when weight has been stable for the most recent 6 months.

ANY of the following

Primary purpose is improving appearance or cosmesis.
Performed solely to repair abdominal wall laxity or diastasis recti (without separate criteria met).
Performed in conjunction with abdominal or gynecologic procedures (e.g., hernia repair, hysterectomy, obesity surgery) unless panniculectomy/lipectomy criteria are met independently.
Performed to minimize the risk of hernia formation or recurrence; evidence does not support that pannus removal prevents hernia.

ALL of the following

Dermabrasion is considered reconstructive and reasonable and necessary when performed for treatment of rhinophyma.
Dermabrasion is considered reconstructive and reasonable and necessary when correcting defects resulting from traumatic injury, surgery, or disease.
Dermabrasion performed for post-acne scarring is considered cosmetic and not reasonable and necessary.

ALL of the following

Lipectomy in these areas is considered reconstructive and reasonable and necessary when removal of excess tissue is required to restore function or treat complications from disease, trauma, or congenital abnormality (e.g., recurrent infections, ulceration, interference with mobility or activities of daily living).
Documentation should demonstrate the functional impairment or medical complication attributable to the excess tissue and failure of conservative measures.

ANY of the following

Considered reconstructive and reasonable and necessary when performed to restore hair loss due to burn injury, trauma, or tumor resection resulting in functional impairment or to correct an abnormal structure.
Hair transplantation for androgenetic or pattern hair loss or purely cosmetic hair restoration is considered not reasonable and necessary.

ANY of the following

Blepharoplasty performed solely for cosmetic improvement without documented functional impairment (e.g., visual field deficit) is cosmetic and not covered.
Rhinoplasty performed solely for aesthetic improvement without functional nasal obstruction due to trauma or disease is cosmetic and not covered.
Scar revision performed solely for cosmetic appearance without functional impairment is cosmetic and not covered.
Liposuction performed solely for body contouring or cosmetic fat removal is cosmetic and not covered.
Chemical exfoliation, dermabrasion for post-acne scarring, and electrolysis when performed for cosmetic reasons are not reasonable and necessary.

ALL of the following

Breast reconstruction of the affected and contralateral breast following a medically necessary mastectomy or lumpectomy is considered reconstructive and reasonable and necessary in accordance with Medicare NCD 140.2.
Coverage includes external breast prostheses and bras, implantable breast prostheses when indicated, and related reconstructive services as described in NCD 140.2 and the Women’s Health and Cancer Rights Act (WHCRA).
Adjunctive items and services related to reconstruction (e.g., pneumatic compression devices for post-mastectomy lymphedema) are covered when medically necessary.

Policy History / Updates

Policy history items affecting coverage rationale and diagnosis coding updates are summarized below and incorporated into the criteria above. Providers should note these changes for documentation and billing.

Coverage Rationale Changes (policy history)

Clarified distinction between reconstructive and cosmetic indications across multiple procedures; added explicit examples where dermabrasion and punch graft hair transplant are reconstructive vs cosmetic.
Expanded abdominal lipectomy/panniculectomy criteria to require 3 months of refractory symptoms and specified weight-stability and bariatric-surgery timing requirements (>=6 months stable weight; >=18 months post-bariatric surgery before lipectomy).
Affirmed Medicare NCD 140.2 applicability for breast reconstruction following mastectomy and explicitly listed associated covered services (external prostheses, implantable prostheses, pneumatic compression devices, and ADM use where indicated referencing commercial policy guidance).

Diagnosis Code Additions (policy history)

Added diagnosis codes to support panniculus-associated conditions, chronic intertrigo/dermatitis, and ulceration related to pannus when applicable; providers should append the most specific ICD-10-CM codes documenting location and complication (e.g., intertrigo, ulcer).
Operational: use specific ICD-10-CM codes for billable claims; maintain supporting clinical documentation.
Added diagnosis coding guidance to capture burn- or trauma-related alopecia for reconstructive punch graft hair transplant claims; document etiology (burn/trauma/tumor resection) in the record.

Obtain any required prior authorization per the member's benefit plan and applicable delegated processes. When LCDs/LCAs apply, consult and follow those local Medicare policies and cite them in the authorization request. For Medicare Advantage members, review member‑specific benefit limitations and consult CMS materials as needed.

Include copies of preoperative photos, documentation of symptom duration and prior conservative care, weight stability records, and functional impairment assessment with the prior authorization submission
If delegated, follow the delegate's prior authorization process and note LCD/LCA references in the submission

Billing Rule

Billing and Claims

Before billing, ensure claims accurately reflect services rendered using standard coding and modifiers. Retain and submit supporting documentation if requested. Failure to document required medical necessity elements, to follow LCDs/LCAs, or to obtain required prior authorization when applicable may result in claim denial or recoupment.

Use appropriate CPT/ICD‑10‑CM codes and modifiers for panniculectomy versus cosmetic abdominoplasty and for any concurrent procedures
Maintain documentation (photos, weight history, evidence of conservative therapy, functional impairment assessment, prior authorization) for audit

Guideline notes increased BMI linked to higher surgical complications.

Evidence summary: CMS/other: Insufficient high-quality evidence that panniculectomy performed concurrently with abdominal or gynecologic surgery outweighs negative outcomes; additional literature needed.

Multiple systematic reviews and cohort studies show mixed outcomes (lower hernia recurrence but higher wound morbidity when concurrent with ventral hernia repair).

Findings from systematic reviews and cohort studies (impact on decision-making)

Key findings from systematic reviews and cohort studies that inform coverage decisions for panniculectomy and related procedures:

Rasador et al. 2024: Concurrent panniculectomy with ventral hernia repair: lower hernia recurrence (RR 0.74; 95% CI 0.62-0.89) but increased surgical-site infection (RR 1.31; 95% CI 1.13-1.51), surgical-site occurrence (RR 1.49; 95% CI 1.26-1.77), skin necrosis (RR 2.94; 95% CI 1.26-6.85), reoperation (RR 1.73; 95% CI 1.32-2.28), and longer hospital stay (+0.90 days).follow-up 1-36 months

Systematic review/meta-analysis

Kalmar et al. 2022: Retrospective study (N=11,137): functional panniculectomy associated with higher overall adverse events, medical and surgical complications, readmission, and reoperation compared with cosmetic abdominoplasty.

Retrospective cohort

Sosin et al. 2020: SVHRP (N=917): high surgical-site occurrence (27.9%) with mean hernia recurrence 4.9%; common complications include superficial infection (15.8%) and seroma (11.2%).mean follow-up ~17.8 months

Meta-analysis

Gebran et al. 2021: Panniculectomy with bariatric surgery (small matched cohort N=124): no significant increase in 30-day mortality, wound complications, readmission, or reoperation; wound complications associated with BMI>50.30-day outcomes

Retrospective cohort

Nag et al. 2021 / SOGC: Panniculectomy with gynecologic surgery in obese patients: evidence doesn't demonstrate consistent benefit and shows increased negative outcomes; perform with caution and consider postoperative antibiotics for open hysterectomy.

Systematic review and guideline note

Rectus diastasis reviews: Systematic reviews (Olsson, Van Kerckhoven, Gormley) indicate rectus diastasis repair may improve functional outcomes across small heterogeneous studies but lack standardized outcome instruments limiting conclusions.

Heterogeneous small studies

Dermabrasion evidence summary

Evidence summary for dermabrasion procedures and limitations of the evidence:

Randomized trial: Alkhatib et al. (2025) small RCT: dermabrasion combined with intradermal hyaluronic acid showed POSAS improvement at 6 months versus baseline; study limited by small sample size (n=10 randomized patients completed) and short follow-up.6 months follow-up

Small RCT

Systematic review - rhinophyma: Benyo et al. (2021): dermabrasion is one of multiple techniques for severe rhinophyma management, often adjunctive after debulking; evidence limited and heterogeneous.

Systematic review

Case series: Clarós et al. (2018) retrospective case series for rhinophyma reported improved quality of life and no recurrence in a small sample (n=12) but limited by design and size.

Retrospective case series

Post-burn leukoderma review: Maranda et al. (2018) systematic review: dermabrasion with thin split-thickness grafting provided satisfactory repigmentation in included studies; limited patient numbers and heterogeneous methods.

Systematic review of case reports/series

Top evidence cited

Rasador 2024Meta-analysis: concurrent panniculectomy lowers hernia recurrence (RR 0.74; 95% CI 0.62-0.89) but increases SSI (RR 1.31), surgical-site occurrence (RR 1.49), skin necrosis (RR 2.94), reoperation (RR 1.73), and hospital stay (+0.90 days); follow-up 1-36 months.

Sosin 2020SVHRP: surgical-site occurrence 27.9%; mean hernia recurrence 4.9%; superficial infection 15.8%; seroma 11.2%; mean follow-up 17.8 ±7.7 months.

Kalmar 2022Retrospective cohort (N=11,137): functional panniculectomy associated with higher overall adverse events, medical and surgical complications, readmission, and reoperation versus cosmetic abdominoplasty.

Alkhatib 2025Small RCT (n=10 randomized completers): dermabrasion ± intradermal hyaluronic acid showed POSAS improvement at 6 months; limited by small sample size.

Maranda 2018Systematic review of surgical options for post-burn leukoderma (20 articles, 264 patients): dermabrasion + thin split-thickness grafting reported satisfactory repigmentation in included studies.

Dalaei 2024Longitudinal cohort (n=5,620): body contouring after bariatric surgery associated with sustained HRQL improvements vs bariatric surgery alone.

Marouf & Mortada 2021Meta-analysis: postbariatric body contouring overall complication rate 31.5%; BMI >=30 increases complication risk by ~37%.

Stoneburner et al. 2020 (Hair transplant)Systematic review/meta-analysis: high graft survival and satisfaction for micrografts/minigrafts in scarring and nonscarring alopecia.

Systematic review (Rasador et al. 2024) and related evidence summarized regarding concurrent panniculectomy and ventral hernia repair demonstrating lower hernia recurrence but increased wound morbidity; evidence informs coverage rationale distinguishing reconstructive vs cosmetic indications.

Archivedarchival

Prior policy version MMP022.14 archived (referenced in 06/01/2026 policy history).

06/01/2026coding_changeLatest

Administrative/coding list change: CPT code 15819 removed from Cosmetic and Non-Covered list (cosmetic/non-covered list updated).