ModifiedFidelis CarePolicy CP.FC.51

Cosmetic and Reconstructive Procedures

Governs when cosmetic and reconstructive surgeries are considered medically necessary or not for Fidelis Care health plans (excluding Medicare), and outlines documentation and coding implications; affects providers submitting claims and Medical Director determinations.

Policy Summary

PayerFidelis Care

PolicyCosmetic and Reconstructive Procedures

Policy CodePolicy CP.FC.51

Change TypeMaterial revisions (criteria edits & exemptions) and operational cross-references

Effective Date

Next Review Date

Key ActionObtain prior authorization and submit medical records with photographs as applicable to support reconstructive procedure claims.

SourceLink

POLICY UPDATE CHANGES

Moved the note for gender dysphoria above criteria and clarified that gender-affirming procedures are exempt from this policy.

Added criterion that skin tag removal is covered when located in an area that affects eyesight.

Replaced the term 'standard' with 'conservative' in scar/keloid management criterion.

Added criteria to I.A.2. to include in an area that affects eyesight.

Added note to see MC.CP.MP.31 for Medicare health plans.

~200+CPT/HCPCS codes listed

~30+Procedure codes in coding section

IMedically necessary criteria section

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Coverage Criteria

Medically necessary reconstructive procedures

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

Intent criteria

A. Intent options
- 1.: 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).
- 2.: Skin tag removal 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).
- 3.: Scar or keloid revision/removal when accompanied by pain unresponsive to conservative therapy and is recurrently infected, unstable, friable, or when there is functional impairment.
- 4.
  - 4.a: Post-mastectomy, medically necessary lumpectomy, or other medically necessary breast surgery resulting in asymmetry: breast reconstruction, including nipple reconstruction, tattooing and surgery on the contralateral breast to restore symmetry.
  - 4.b
    4.b.i: Diagnosis of HIV (human immunodeficiency virus) or AIDS (acquired immunodeficiency syndrome).
    4.b.ii: Diagnosis of facial lipodystrophy syndrome (LDS).

Documentation: Medical records with photographs are provided, as applicable.

Not medically necessary / Cosmetic procedures

The following procedures are considered cosmetic and not medically necessary (examples include, but are not limited to):

Cosmetic procedures considered not medically necessary: Excision of excessive skin; body contouring; body lift; breast augmentation; liposuction (excluding lipoma as directed by clinical decision support criteria); surgery to correct unsatisfactory results from previous cosmetic and/or non-covered service; revision, removal, or replacement of breast implants previously placed for cosmetic reasons; removal of excess skin or body contouring following weight loss or bariatric surgery when removal is solely cosmetic; facial augmentation; abdominoplasty; dermabrasion; skin rejuvenation and resurfacing; electrolysis and laser hair removal; hair transplantation when not performed to correct permanent hair loss caused by disease or injury; tattooing (except when covered for breast reconstruction post-mastectomy); injectable filler; circumcision revisions done only to improve appearance; mastopexy (except post-mastectomy or when medically necessary after other breast surgery resulting in significant asymmetry); correction of inverted nipples; repair of diastasis recti; and breast reconstruction for fibroadenomas or other benign lesions unless medically necessary per clinical decision support criteria.

General medical necessity and plan precedence

Policy incorporates criteria (I.A.2., I.A.3.) and references external standards; specific coverage is subject to meeting policy criteria and member benefit terms.

General: Procedures must meet the policy's medical necessity criteria and be consistent with the member's coverage documents. Coverage decisions and administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents and to applicable state and federal requirements.

For Medicare members, review applicable NCDs, LCDs and Medicare Coverage Articles (see MC.CP.MP.31); for Medicaid members, state Medicaid provisions take precedence when in conflict.

Note: Gender-affirming procedures related to treatment of gender dysphoria are exempt from this clinical policy and are handled under separate, applicable policies and guidance.

This policy provides guidance on medical necessity but does not itself guarantee coverage or payment. Coverage decisions and the administration of benefits are subject to the member's specific coverage documents (for example, evidence of coverage, certificate of coverage, policy or contract) and applicable state and federal requirements.

Cosmetic surgery performed solely to improve a patient’s normal appearance and self‑esteem is not medically necessary and is generally not a covered benefit. Examples include, but are not limited to, procedures such as excision of excessive skin, body contouring, breast augmentation, abdominoplasty, dermabrasion, injectable fillers, and hair transplantation when not correcting permanent hair loss from disease or injury.

This clinical policy is intended as a guide to medical necessity used to assist in making coverage determinations and administering benefits. It is not a contract, does not in itself constitute coverage or a guarantee of payment, and may be changed, amended, or withdrawn by the Health Plan.

Coding and Procedure Codes

Covered CPT Codes - selectionCPT

11200	Removal of skin tags, multiple fibrocutaneous tags; up to and including 15 lesions.
11201	Removal of skin tags; each additional 10 lesions (list separately).
11400	Excision, benign lesion, trunk/arms/legs; excised diameter 0.5 cm or less.
11401	Excision, benign lesion, trunk/arms/legs; excised diameter 0.6 to 1.0 cm.
11402	Excision, benign lesion, trunk/arms/legs; excised diameter 1.1 to 2.0 cm.
11403	Excision, benign lesion, trunk/arms/legs; excised diameter 2.1 to 3.0 cm.
11404	Excision, benign lesion, trunk/arms/legs; excised diameter 3.1 to 4.0 cm.
11406	Excision, benign lesion, trunk/arms/legs; excised diameter over 4.0 cm.
11420	Excision, benign lesion, scalp/neck/hands/feet/genitalia; excised diameter 0.5 cm or less.
11421	Excision, benign lesion, scalp/neck/hands/feet/genitalia; excised diameter 0.6 to 1.0 cm.

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Additional Covered CPT Codes - selectionCPT

17110	Destruction of benign lesions other than skin tags; up to 14 lesions.
17111	Destruction of benign lesions other than skin tags; 15 or more lesions.
19301	Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy).
19302	Mastectomy, partial with axillary lymphadenectomy.
19303	Mastectomy, simple, complete.
19316	Mastopexy.
19318	Breast reduction.
19325	Breast augmentation with implant.
19328	Removal of intact breast implant.
19330	Removal of ruptured breast implant, including implant contents.

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Facial/Craniofacial CPT Codes - selectionCPT

21120	Genioplasty; augmentation (autograft, allograft, prosthetic material).
21121	Genioplasty; sliding osteotomy, single piece.
21122	Genioplasty; sliding osteotomies, 2 or more.
21123	Genioplasty; sliding, augmentation with interpositional bone grafts.
21137	Reduction forehead; contouring only.
21138	Reduction forehead; contouring with prosthetic material or bone graft.
21139	Reduction forehead; contouring and setback of anterior frontal sinus wall.
21159	Reconstruction midface, LeFort III with forehead advancement; without LeFort I.
21160	Reconstruction midface, LeFort III with forehead advancement; with LeFort I.
21172	Reconstruction superior-lateral orbital rim and lower forehead, with or without grafts.

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Provider Actions and Authorization

Billing Rule

Coding and prior authorization guidance

Providers should reference and code per the current CPT/HCPCS manuals and professional coding guidance prior to claim submission. Inclusion or exclusion of codes in this policy is informational only and does not guarantee coverage.

Reference current CPT/HCPCS and payer coding guidance prior to billing
Inclusion/exclusion of codes in policy is informational only

Prior Authorization

Prior Authorization Required

Prior authorization is expected for the surgical and injectable procedures listed in this policy per plan requirements. Verify prior authorization requirements with the member's benefit plan and obtain approval before scheduling non-emergent procedures.

Definitions

Functional impairment — definition and examples

DefinitionFunctional impairment: normal function of a body part or organ system is less than age appropriate at full capacity (e.g., decreased range of motion, diminished eyesight or hearing) that variably impacts activities of daily living.

Examples — range of motionDecreased range of motion of a limb or joint that limits self-care or work tasks (e.g., inability to dress, bathe, or perform job duties).

Examples — sensory deficitsDiminished eyesight or hearing resulting from anatomic abnormality or sequelae of disease that interferes with activities such as reading, driving, or communication.

Examples — interference with activitiesConditions causing recurrent infection, instability, friability, or pain that prevent normal activities of daily living or occupational tasks.

Dermal filler for LDS — coding note

Dermal filler for facial LDS

Background

Background: Reconstructive surgery is performed on abnormal structures of the body—resulting from congenital defects, developmental abnormalities, trauma, infection, tumors, or disease—with the primary intent to restore or improve function. By contrast, cosmetic surgery reshapes normal structures to improve appearance and self‑esteem and is generally not considered medically necessary. Documentation that demonstrates functional impairment or a medical indication for reconstruction is required to support medical necessity determinations.

Revision History

07/24revision

New policy created and note added to see MC.CP.MP.31 for Medicare health plans; moved gender dysphoria note above criteria; added criterion to I.A.2. for lesions in areas that affect eyesight; replaced 'standard' with 'conservative' in I.A.3.; references updated.

05/2025annual review/revisionLatest

Annual review and revision: restated cross-reference to MC.CP.MP.31 for Medicare plans; moved gender dysphoria note above criteria; added eyesight-related criterion to I.A.2.; replaced 'standard' with 'conservative' in I.A.3.; references reviewed and updated.