CurrentCommunity Health Plan WashingtonPolicy MC.CP.MP.31

Cosmetic and Reconstructive Procedures

Medical necessity criteria and coding guidance for reconstructive and cosmetic surgical procedures for members of Community Health Plan Washington / Centene-affiliated Medicare plans; supplements applicable LCDs and applies when no procedure-specific criteria exist.

Policy Summary

PayerCommunity Health Plan Washington

PolicyCosmetic and Reconstructive Procedures

Policy CodePolicy MC.CP.MP.31

Change TypeCriteria removeddescription revisededitorial clarifications

Effective Date

Next Review Date

Key ActionVerify benefit plan limitations and submit prior authorization documentation showing the policy criteria are met when no procedure-specific criteria exist.

SourceLink

POLICY UPDATE CHANGES

Removed Criteria I.A.4. regarding certain procedures that may be covered if improving appearance is the only benefit.

Policy description updated to note that the applicable LCDs do not provide sufficient coverage criteria to consistently determine medical necessity in all clinically appropriate scenarios.

Updated verbiage in Note under Description section for clarity.

>=27references

3reconstructive indications

5LCDs cited

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Coverage and Medical Necessity Criteria

COVERAGE CRITERIA

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

Overall requirement: Procedure intent and specific condition-based criteria

Intent of procedure (one required)

Improve function of an abnormal body part: The procedure is performed to 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).
Conservative therapy must have failed prior to reconstructive procedures unless not standard of care or contraindicated.
Skin tag removal: Removal of skin tags when located in an area that affects eyesight or in an area of friction with documentation of repeated irritation and bleeding (refer to Benefit Plan Contract for any coverage restrictions).
Document location and repeated irritation/bleeding.
Scar/keloid revision or removal: Scar or keloid revision/removal when accompanied by pain unresponsive to conservative therapy and is recurrently infected, unstable, friable, or associated with functional impairment.
Document failure of conservative therapy and evidence of recurrent infection, instability/friability, pain, or functional impairment.

General medical necessity guidance

Policy-level guidance and applicability notes to assist coverage determination.

Policy-level requirements: Coverage decisions must follow the member's coverage documents and any applicable state Medicaid rules; providers should review applicable Medicare NCDs/LCDs and exercise professional judgment when applying this policy.

The policy notes that applicable LCDs do not always provide sufficient criteria to consistently determine medical necessity in all clinically appropriate scenarios; one prior criterion (I.A.4) was removed as documented in the revision history.

It is the policy of Medicare Health Plans affiliated with Centene Corporation that cosmetic surgery performed for the sole purpose of improving appearance is not medically necessary and is not a covered benefit.

This clinical policy does not replace or modify the member's benefit plan contract, applicable exclusions, limitations, or state or federal law. Providers must consult the member's coverage documents and plan terms to determine whether a service is covered before rendering or billing for services.

For clarity, cosmetic surgery that is performed solely to improve appearance is considered not medically necessary and therefore is not a covered benefit under Medicare Health Plans affiliated with Centene Corporation.

The policy was revised to remove a prior criterion (Criteria I.A.4) that had allowed coverage for certain procedures when improving appearance was the only benefit. This criterion has been removed from the medical necessity criteria set.

Procedure and Coverage Coding

CPT codes that support 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 (List separately in addition to code for primary procedure).
11400	Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less.
11401	Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm.
11402	Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm.

Additional CPT/HCPCS codes referencedmixedCovered

11403	Excision, benign lesion including margins; excised diameter 2.1 to 3.0 cm.
11404	Excision, benign lesion including margins; excised diameter 3.1 to 4.0 cm.
11406	Excision, benign lesion including margins; excised diameter over 4.0 cm.
11420	Excision, benign lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less.
11421	Excision, benign lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm.
11422	Excision, benign lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm.
11423	Excision, benign lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm.
11424	Excision, benign lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm.
11426	Excision, benign lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm.
11440	Excision, other benign lesion including margins, face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less.

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Additional CPT/HCPCS codes referenced (continued)mixedCovered

15771	Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate.
15772	Grafting of autologous fat; each additional 50 cc injectate.
15775	Punch graft for hair transplant; 1 to 15 punch grafts.
15776	Punch graft for hair transplant; more than 15 punch grafts.
15838	Excision, excessive skin and subcutaneous tissue; submental fat pad.
15839	Excision, excessive skin and subcutaneous tissue; other area.
15847	Excision, excessive skin and subcutaneous tissue, abdomen (eg, abdominoplasty).
15876	Suction assisted lipectomy; head and neck.
15877	Suction assisted lipectomy; trunk.
15878	Suction assisted lipectomy; upper extremity.

1–10 of 15

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Referenced NCDs/LCDs and identifiersmixed

L33428	Local coverage determination: cosmetic and reconstructive surgery.
L39506	Local coverage determination: cosmetic and reconstructive surgery.
L38914	Local coverage determination: cosmetic and reconstructive surgery.
L35090	Local coverage determination: cosmetic and reconstructive surgery.
L39051	Local coverage determination: cosmetic and reconstructive surgery.
140.2	National coverage determination: breast reconstruction following mastectomy.
250.5	National coverage determination: dermal injections for treatment of facial lipodystrophy syndrome (LDS).

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization: confirm coverage and submit supporting documentation

Verify member benefits, plan-specific limitations, and submit prior authorization when required. This policy should only be used when no procedure-specific criteria exist. For non‑Medicare plans, see CP.MP.31 Cosmetic and Reconstructive Procedures. Prior authorization submissions must include supporting clinical documentation demonstrating medical necessity (see documentation callout).

Use this policy only if no procedure‑specific criteria are available.
For non‑Medicare plans, refer to CP.MP.31 Cosmetic and Reconstructive Procedures.
Include clinical records, prior conservative therapy documentation, and treatment intent when requesting prior authorization.

Note

Verify policy effective date and applicable Medicare LCD/NCDs

Review the effective date of this clinical policy against the Health Plan’s posted effective date and any applicable Medicare NCDs/LCDs. The Health Plan may change or withdraw this clinical policy; where discrepancies with legal or regulatory requirements exist, law and regulation govern. For Medicare members, review all applicable NCDs, LCDs and Medicare Coverage Articles prior to applying this policy’s criteria.

Background and Rationale

Reconstructive surgery is intended to treat abnormal body structures resulting from congenital defects, developmental abnormalities, trauma, prior surgery, infection, tumors, or disease with the goal of improving function and relieving pain or irritation. These procedures address functional impairment of an anatomical part rather than altering normal structures for cosmetic appearance. Risks of reconstructive procedures include infection, scarring, poor wound healing, bleeding, thrombosis, and anesthesia-related complications.

Definitions and Policy Scope

Functional impairment definition

DefinitionFunctional impairment is 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.

Examples of affected functionsDecreased range of motion; diminished eyesight; diminished hearing.

Impact on daily lifeVariably impacts activities of daily living (ADLs), e.g., difficulty dressing, feeding, mobility, or communication due to reduced function.

Clinical relevanceUsed to determine medical necessity for reconstructive procedures intended to improve function of an abnormal body part.

Clinical policy purpose

PurposeProvides a guide to medical necessity to assist in making coverage decisions and administering benefits.