CurrentCommunity Health Plan WashingtonPolicy MC.CP.MP.31

Cosmetic and Reconstructive Procedures

Defines medical necessity criteria and coding guidance for reconstructive and cosmetic surgical procedures for Medicare Health Plans affiliated with Centene Corporation; supplements LCDs and applies to providers submitting claims to the plan.

Policy Summary

PayerCommunity Health Plan Washington

PolicyCosmetic and Reconstructive Procedures

Policy CodePolicy MC.CP.MP.31

Change TypeClarification and removal of non‑material criteria

Effective Date

Next Review Date

Key ActionDocument that the procedure is intended to improve function (not solely appearance) and that conservative therapy has failed unless contraindicated.

SourceLink

POLICY UPDATE CHANGES

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.

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

Updated verbiage in Note under Description section for clarity.

1Reference LCDs cited

dozensCPT/HCPCS codes listed

MedicarePrimary population

12/25Most recent approval

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.

Coverage Criteria for Reconstructive and Cosmetic Procedures

Medically necessary reconstructive procedures

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

Intent and prerequisites: 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).

From Policy I.A.1

Specific covered indications: Includes: (a) skin tag removal when located in an area that affects eyesight or in an area of friction with documentation of repeated irritation and bleeding; (b) scar or keloid revision/removal when accompanied by pain unresponsive to conservative therapy and is recurrently infected, unstable, friable, or associated with functional impairment.

From Policy I.A.2 and I.A.3

Not covered — Cosmetic surgery

Cosmetic surgery exclusion: Cosmetic surgery performed for the sole purpose of improving appearance is not medically necessary and not a covered benefit for Medicare Health Plans.

Policy II

Cosmetic surgery performed solely to improve appearance is excluded from coverage for Medicare Health Plans. This means procedures done only for aesthetic enhancement, without demonstrable functional impairment or other medically necessary indications, are not considered a covered benefit under Medicare plans affiliated with Centene Corporation.

For Medicaid members/enrollees, state Medicaid coverage provisions take precedence when they conflict with this clinical policy. Providers should consult the applicable state Medicaid manual and follow state-specific coverage rules where discrepancies exist between state requirements and this policy.

Procedures whose sole intent is to improve appearance (cosmetic procedures) are not medically necessary and are not a covered benefit for Medicare Health Plans. Coverage requires that procedures be performed for medical indications—such as to improve function of an abnormal body part—rather than exclusively for cosmetic reasons.

Coding Guidance and Code Lists

CPT codes (skin tag / benign lesion excision group)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, trunk, arms or legs; excised diameter 0.5 cm or less.
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.

CPT and HCPCS codes (mixed reconstructive procedures)mixedCovered

11403	Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter 2.1 to 3.0 cm.
11404	Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter 3.1 to 4.0 cm.
11406	Excision, benign lesion including margins, except skin tag, trunk, arms or legs; 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.
11920	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin; 6.0 sq cm or less.
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.
15830	Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy.
17110	Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags; up to 14 lesions.
19301	Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy).
19325	Breast augmentation with implant.

1–10 of 17

1/2

inv-08: Lesion counts / sizes — code-specific size ranges and lesion count details

Skin tag counts11200 describes removal of skin tags up to and including 15 lesions; 11201 is for each additional 10 lesions or part thereof (listed separately).

Benign lesion size ranges (trunk/arms/legs)11400 = excised diameter 0.5 cm or less; 11401 = 0.6–1.0 cm; 11402 = 1.1–2.0 cm; additional codes (11403–11406) cover larger diameters.

Benign lesion size ranges (scalp/neck/hands/feet/genitalia)11420 (and subsequent site-specific codes) specify excised diameter thresholds (example: 11420 = 0.5 cm or less for listed sites).

Destruction / multiple lesion thresholds17110 describes destruction of benign lesions for up to 14 lesions (threshold for number of lesions treated).

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization — confirm plan process

Prior authorization may be required for certain reconstructive procedures. Codes listed in the policy are for reference only; providers must confirm plan-specific prior authorization processes and submit any required documentation per the Health Plan's instructions before performing non-emergent services.

Confirm plan-specific prior authorization requirements and submission pathway
Codes in policy are informational and do not guarantee coverage

Note

Plan Effective Date and Administrative Compliance

This clinical policy is effective as of the date determined by the Health Plan; the date of posting may not be the effective date. The Health Plan may change, amend, or withdraw this clinical policy at any time. Coverage decisions remain subject to all terms, conditions, exclusions, and limitations of the member's benefit plan.

Follow the Health Plan’s posted effective date for authorization and coverage decisions
Coverage subject to benefit contract terms, exclusions, and limitations

Background on Reconstructive Surgery

Reconstructive surgery is performed to correct or restore abnormal body structures resulting from congenital defects, developmental abnormalities, trauma, previous surgery, infection, tumors, or disease. The primary goal of reconstructive procedures is to improve function of an affected body part; improvement in appearance may occur but is secondary to restoring function. Typical clinical scenarios include repair after trauma, restoration following tumor resection (for example breast or facial reconstruction), correction of congenital anomalies, and treatment of complications from prior surgery or disease. Because reconstructive procedures carry risks such as infection, scarring, poor wound healing, bleeding, thrombosis, and anesthesia-related complications, they should be performed only when clinically indicated and when conservative therapies have failed or are not appropriate.

Key Definitions

inv-18: Definition of Functional impairment

Functional impairment (definition)A health condition in which normal function of a body part or organ system is less than age-appropriate capacity (e.g., decreased range of motion, diminished eyesight or hearing) that variably impacts activities of daily living.

Context of reconstructive proceduresReconstructive surgery is performed on abnormal body structures caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease to improve function and sometimes appearance.

Implication for coverageProcedures intended to restore or improve function for conditions causing functional impairment are evaluated as reconstructive (medically necessary) rather than cosmetic.

inv-19: Definition of Clinical policy — guidance to assist coverage decisions, not a guarantee of payment

Purpose of clinical policyProvides a guide to medical necessity to assist in making coverage decisions and administering benefits.