ModifiedEmblemHealthPolicy MG.MM.AD.20b

Cosmetic and Reconstructive Surgery Procedures

Defines when surgical and related procedures are considered cosmetic versus reconstructive/medically necessary for EmblemHealth commercial and Medicaid plans, and lists procedure codes deemed always cosmetic or requiring review.

Policy Summary

PayerEmblemHealth

PolicyCosmetic and Reconstructive Surgery Procedures

Policy CodePolicy MG.MM.AD.20b

Change TypeAdded reconstructive criteriacoding/table updates

Effective Date

Next Review DateOct 10, 2025

Key ActionSubmit clinical evidence with prior authorization requests to demonstrate the member meets reconstructive criteria (documentation of functional impairment and expected restoration of physiological function).

SourceLink

POLICY UPDATE CHANGES

Added reconstructive clinical criteria for prefabricated external infant ear molding systems (e.g., EarWell®, InfantEar™) (CPT 21086).

Transferred policy content to individual company branded template and updated Table 2 header link.

Multiple CPT codes were moved into or out of the 'always cosmetic' table and cross-references to other medical policies were updated across prior revisions.

Table 1 & Table 2Coding tables provided

Commercial & MedicaidPlan applicability

ManyAlways cosmetic codes

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 — Reconstructive vs Cosmetic

inv-01: Indications for Coverage

Covered as reconstructive and medically necessary when ALL of the following are met:

Reconstructive criteria: There is documentation that the physical abnormality and/or physiological abnormality is causing a functional impairment that requires correction; and the proposed treatment is of proven efficacy and is deemed likely to significantly improve or restore the patient's physiological function.

inv-02: Reconstructive vs Cosmetic coverage criteria

Not covered when performed solely for cosmetic reasons; may be covered when ALL of the following apply:

Medical necessity for reconstructive consideration: Procedure corrects or treats a medical condition or restores physiologic function (not solely to improve appearance)

Psychological impact or improved self-esteem alone does not meet this requirement; see Definitions (Cosmetic surgery vs Reconstructive Procedures).

Functional impairment documented: Medical record documents significant impairment of physical or mechanical function attributable to the condition addressed by the procedure

Many CPT entries in Table 1 include 'Medical record review required. May be considered medically necessary when causing significant impairment of physical or mechanical function.'

Procedures that correct an anatomical congenital anomaly but do not improve or restore physiologic function are considered cosmetic and are not covered. Coverage as reconstructive and medically necessary requires documentation showing that a physical or physiological abnormality is causing a functional or physical impairment and that the proposed procedure is proven and likely to restore or significantly improve physiological function. The Plan does not cover pharmacological regimens, nutritional procedures, scar or tattoo removal or revision, skin abrasion for acne, or other treatments performed only to improve appearance.

Benefit coverage is determined by the member-specific plan document and applicable law; when a procedure is performed to correct a congenital anomaly, the clinical record must clearly demonstrate functional impairment and the likelihood that the intervention will restore physiologic function for the service to be considered reconstructive.

Cosmetic procedures are those performed solely to refine or reshape structures that are not functionally impaired and are intended to improve appearance, self‑esteem, or address psychological, psychiatric, or emotional concerns. Psychological impact alone does not meet reconstructive criteria.

Because cosmetic procedures are usually not eligible for coverage, documentation that describes only aesthetic benefit or psychological distress—without objective evidence of physiologic or mechanical functional impairment—will not satisfy the requirements for medical necessity.

Surgical procedures listed in the Applicable Coding Tables are regarded as cosmetic (not medically necessary) unless the treating provider submits substantiating documentation demonstrating that the purpose of the procedure is to restore or improve bodily function or is otherwise medically necessary.

Providers must include clinical evidence in the medical record that the member meets reconstructive criteria (objective documentation of functional impairment and the expected physiologic benefit) when requesting coverage for codes from the tables.

The codes listed in Table 1 are designated as always cosmetic and are usually not eligible for coverage. Claims billed with these codes risk denial unless the provider supplies documentation that justifies medical necessity by demonstrating significant impairment of physical or mechanical function.

Several entries in Table 1 include comments such as “Medical record review required. May be considered medically necessary when causing significant impairment of physical or mechanical function,” which means prior authorization and thorough documentation may allow coverage in exceptional, function‑restoring circumstances.

Procedure Codes and Coding Tables

Procedure codes deemed always cosmeticCPTNot Covered

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
11950	Subcutaneous injection of filling material (eg, collagen) (Exception: NY and Mass HIV-related lipodystrophy mandate)
11951	Subcutaneous injection of filling material (eg, collagen) (Exception: NY and Mass HIV-related lipodystrophy mandate)
11952	Subcutaneous injection of filling material (eg, collagen) (Exception: NY and Mass HIV-related lipodystrophy mandate)
11954	Subcutaneous injection of filling material (eg, collagen) (Exception: NY and Mass HIV-related lipodystrophy mandate)
15775	Punch graft for hair transplant
15776	Punch graft for hair transplant: more than 15 punch grafts
15786	Abrasion; single lesion (eg, keratosis, scar)
15787	15787

1–10 of 87

1/9

Procedure codes listed as always cosmeticCPTNot Covered

21181	Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranial.
21182	Reconstruction (related description as listed in table).
21183	Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following excision of benign tumor of cranial bone; multiple autografts; total area of bone grafting >40 sq cm but <80 sq cm.
21184	Reconstruction ... total area of bone grafting >80 sq cm.
21230	Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft).
21235	Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft).
21242	Arthroplasty, temporomandibular joint, with allograft.
21243	Arthroplasty, temporomandibular joint, with prosthetic joint replacement.
21256	Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia).
21260	Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach.

1–10 of 63

1/7

Age threshold for auricular prosthesis

Age threshold for auricular prosthesis≤ 8 weeks of age at treatment initiation for impression and custom preparation; auricular (CPT 21086)

Bone graft area thresholds

21183 bone graft area thresholdTotal area of bone grafting greater than 40 sq cm but less than 80 sq cm (CPT 21183)

21184 bone graft area thresholdTotal area of bone grafting greater than 80 sq cm (CPT 21184)

Medical record review noteMedical record review required; may be considered medically necessary when causing significant impairment of physical or mechanical function

Provider Actions — Authorization, Documentation, and Billing

Documentation Required

Documentation Submission Requirement

The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the member meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request for preauthorization or post-payment review. Lack of submitted clinical evidence may result in inability to complete review and potential denial of the request.

Treating clinician must provide relevant clinical records, operative notes, imaging, and documentation demonstrating how the member meets the applicable indications for coverage.
When codes listed in Table 1 or Table 2 are billed, include documentation that addresses functional impairment or mechanical dysfunction as applicable.

Prior Authorization

Prior Authorization and Medical Record Review Required

Prior authorization and medical record review are required for certain listed procedure codes. Treating providers must submit supporting documentation with preauthorization requests; medical record review may also be required for post-payment review.

Background and Scope

EmblemHealth treats the surgical procedures listed in the Applicable Coding Tables as cosmetic unless submitted documentation demonstrates the procedure restores or improves bodily function or corrects a functional impairment. Reconstructive coverage requires evidence of a physical or physiological abnormality causing functional impairment and that the proposed treatment is proven and likely to restore physiological function.

Absent such documentation, the plan reserves the right to deny coverage for procedures deemed cosmetic; providers should confirm member benefits and submit required clinical records when seeking prior authorization or coverage consideration.

Definitions

Reconstructive / Medically Necessary

DefinitionProcedure intended to restore or improve physiological function when documentation shows a physical or physiological abnormality is causing functional impairment and the treatment is proven effective.

Coverage implicationEligible as reconstructive and medically necessary when documentation shows functional impairment and proposed treatment is likely to improve or restore physiologic function.

Cosmetic Surgery

DefinitionProcedures intended solely to refine or reshape structures that are not functionally impaired; performed to improve appearance, self-esteem, or for psychological/psychiatric reasons.

Coverage implicationCosmetic surgery procedures are usually not eligible for coverage unless documentation demonstrates restoration/improvement of physiologic function.