CurrentHealth NetPolicy N/A

Clinical Policy: Cosmetic and Reconstructive Surgery

Defines medical necessity criteria for reconstructive surgery and exclusions for cosmetic surgery for Health Net (California), includes examples of covered reconstructive indications, not-covered cosmetic procedures, relevant CPT/HCPCS/ICD-10 codes, and references to state mandates and Medicare LCD L39051.

Policy Summary

PayerHealth Net

PolicyClinical Policy: Cosmetic and Reconstructive Surgery

Policy CodePolicy N/A

Change TypeAnnual review — references updated

Effective Date10/04

Next Review Date

Key ActionProviders must document congenital defects, functional deficiencies, symptoms, failure of prior therapies, or other clinical evidence supporting reconstructive indication and reference state mandates and member benefits.

POLICY UPDATE CHANGES

Annual review—References updated (10/25).

Added language to refer to California reconstructive surgery mandates and noted exceptions for gender dysphoria treatment (11/18 prior revision).

Removed nasal surgery and pectus excavatum sections from medically necessary section in 11/19 (these have InterQual criteria).

~40CPT/ICD codes listed

2Primary coverage categories

1Referenced Medicare LCD

This policy distinguishes reconstructive surgery (procedures to correct abnormal structures caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease, generally to improve function and possibly appearance) from cosmetic surgery (procedures that reshape normal structures to improve appearance and self‑esteem and are generally not medically necessary). It applies to Health Net (California) and is subject to state mandates (California Health and Safety Code) and Medicare Local Coverage Determination L39051. Status: CURRENT; Last review date: 10/25.

Policy Header

PayerHealth Net

PolicyClinical Policy: Cosmetic and Reconstructive Surgery

Policy NumberN/A

StatusCURRENT

Last review10/25

Scope summaryDefines medical necessity criteria for reconstructive surgery and exclusions for cosmetic surgery for Health Net (California), includes examples of covered reconstructive indications, not-covered cosmetic procedures, relevant CPT/HCPCS/ICD-10 codes, and references to state mandates and Medicare LCD L39051.

State mandateCalifornia Health and Safety Code 1367.63 and 1367.6 require coverage for reconstructive surgery and post-mastectomy reconstruction.

Medicare LCDMedicare LCD L39051 referenced for Cosmetic and Reconstructive Surgery.

Not Medically Necessary / Cosmetic

Not Medically Necessary / Cosmetic (General)

Cosmetic surgery is not medically necessary and generally not covered when performed to improve a patient's normal appearance and self-esteem; exceptions may exist (e.g., gender dysphoria treatments). Procedures include but are not limited to:

ANY of the following

Cosmetic surgery performed purely for the purpose of enhancing appearance and/or expenses incurred in connection with such surgery
Cosmetic surgery performed to treat psychiatric or emotional distress, problems or disorders
Flesh color tattooing for treatment of port wine stains, hemangiomas or birthmarks
Dermabrasion, chemical peel, liquid nitrogen, skin grafting, dry ice or CO2 snow unless otherwise specified
Intense pulsed light sources (IPLS) (e.g., PhotoDerm VL) as initial therapy for proliferative vascular disorders such as port wine stains, hemangiomas, spider angiomas, cherry angiomas and facial telangiectasias
Failure of dye laser required before IPLS for reconstructive indications; IPLS as initial therapy is cosmetic
Rhinoplasty for external nasal deformity not due to trauma or disease
Septoplasty performed solely to improve the patient's appearance in the absence of signs/symptoms of functional respiratory abnormalities
Mastopexy (breast lift) to treat sagging of the breast unless otherwise specified
Surgery to correct 'moon face' from cortisone therapy
Removal or revision of a breast implant for non-medical reasons
Otoplasty for bat ears, prominent or protruding ears without functional impairment
Salabrasion
Injection of any filling material (collagen, fat or other autologous or foreign material grafts) unless treatment for facial lipodystrophy
Rhytidectomy (face lift) for aging skin
Excision of excessive skin of thigh or other areas unless otherwise specified
Removal of fatty tissue by lipectomy (suction-assisted liposuction, lipoplasty) unless otherwise specified
Electrolysis or laser hair removal unless specified (e.g., gender-affirming procedures)
Sclerosing of spider veins and/or telangiectasis
Correction of inverted nipples
Excision/correction of glabellar frown lines
Hair transplants to correct male pattern baldness (alopecia) or age-related hair thinning in women
Ear piercing
Buttock or thigh lifts
Facial rejuvenation/plumping/collagen or fat injections (cosmetic)
Neck tucks
Chin implant to improve appearance
Cryotherapy for acne
Epidural chemical peels used to photoaged skin, wrinkles, or acne scarring
Dermal chemical peel used as treatment of end-stage acne scarring
Dermabrasion for wrinkling; pigmentation or severe acne scarring (cosmetic indications)
Chemical exfoliation for acne
Laser resurfacing for wrinkling, aging skin or telangiectasias from rosacea
Insertion or injection of prosthetic material to replace absent adipose tissue (cosmetic)
Augmentation mammoplasty (breast enlargement) of small but otherwise normal breasts unless part of gender-affirming surgery
Phalloplasty (penis enlargement)
Diastasis recti repair in the absence of a true midline hernia without evidence of current or potential incarceration, volvulus, or strangulation of bowel
Excision/treatment of decorative tattoos
Repair/revision of vaccination scars
Reduction of labia minor
Collagen implant (e.g., Zyderm)
Earlobe repair to close a stretched pierce hole
Surgery to change the appearance of a child with Down Syndrome
Vestibuloplasty (when cosmetic)
Vermilionectomy (lip shave) with mucosal advancement (when cosmetic)

Coding (Referenced Codes)

Referenced CPT Codes (informational; inclusion does not guarantee coverage)CPT

11200	Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions
11300-11313	Shaving of epidermal or dermal lesions
11400-	Excision of benign lesions
11920	Tattooing, intradermal... 6.0 sq cm or less
11921	Tattooing, intradermal...
11922	Tattooing, intradermal; each additional 20.0 sq cm or part
11950	Subcutaneous injection or filling material (collagen); 1 cc or less
11951	Subcutaneous injection or filling material
11952	Subcutaneous injection or filling material; 5.1 cc to 10.0 cc
11954	Subcutaneous injection or filling material; over 10.0 cc

1–10 of 51

1/6

Referenced ICD-10 Codes Supporting Coverage CriteriaICD-10

L30.4	Erythema intertrigo
M95.4	Acquired deformity of chest and rib
Q16.0-Q16.9	Congenital malformations of ear causing impairment of hearing (microtia)
Q67.6	Pectus excavatum
Q75.1	Crouzon Syndrome
Q75.4	Treacher-Collins Syndrome
Q79.8	Poland syndrome
Q82.5	Congenital non-neoplastic nevus
D17.0-D17.9	Benign lipomatous neoplasm
D18.01	Hemangioma of skin and subcutaneous tissue

1–10 of 18

1/2

HCPCS / Other (informational)HCPCS

No codes listed

Inclusion or exclusion of CPT/ICD codes or procedures in this policy does not guarantee coverage; codes are provided for informational purposes only. Providers must reference current coding guidance, member benefits, and applicable state or federal mandates when submitting claims.

Provider Actions & Billing Guidance

Documentation Required

Document functional impairment or medical necessity

Providers must document congenital defects, functional deficiencies, symptoms (e.g., bleeding, pain, ulceration), failure of prior therapies (e.g., dye laser before IPLS), or other clinical evidence supporting reconstructive indication; state mandates (California) and member benefits should be referenced.

Congenital defects or developmental abnormalities (e.g., microtia, pectus excavatum, Crouzon's Syndrome, Treacher-Collins Syndrome)
Functional deficiencies or impairment (e.g., decreased range of motion, diminished eyesight or hearing, interference with activities of daily living)
Symptoms such as bleeding, pain, ulceration
Failure of prior therapies where specified (e.g., documented failure of dye laser before IPLS)
Reference applicable state mandates (e.g., California Health and Safety Code requirements) and member benefits/evidence of coverage

Documentation Required

Keloid adjunctive radiation timing

Low-dose radiation must be administered as adjunctive therapy immediately following excisional surgery within 7 days when criteria for keloid removal are met.

Timing requirement: within 7 days post-excision

Billing Rule

Codes are informational; verify coverage

CPT/ICD codes listed are for informational purposes only; inclusion or exclusion does not guarantee coverage and providers should reference current coding guidance when submitting claims.

Verify current CPT/ICD coding guidance prior to claim submission
Listing in this policy does not equal coverage or guarantee payment

Background & Definitions

Reconstructive surgery is performed to correct abnormal body structures caused by congenital defects, developmental abnormalities, prior or concurrent surgeries, trauma, infection, tumors or disease and is generally intended to improve the functioning of a body part and, where possible, restore a normal appearance. Cosmetic surgery is performed to reshape normal structures to improve appearance and self‑esteem and is generally not medically necessary. The policy provides guidelines to differentiate when procedures are considered medically necessary reconstructive care versus noncovered cosmetic care.

Definitions

Reconstructive surgerySurgery performed to correct abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to repair or to create a normal appearance to the extent possible; generally to improve function.

Cosmetic surgerySurgery performed to reshape normal structures of the body to improve appearance and self-esteem; generally not medically necessary.

Key evidence and legal references include Medicare LCD L39051 (Cosmetic and Reconstructive Surgery) and California statutes (Health and Safety Code 1367.63 and 1367.6) which require coverage for reconstructive surgery and post‑mastectomy prosthetic/reconstructive services; these are cited for informational and compliance relevance to coverage determinations.

Revision History

10/25revisedLatest

Annual review—References updated (10/25). Detail: Annual review; References updated per revision history (Last Review Date: 10/25).

11/18added

Added language to refer to California reconstructive surgery mandates and noted exceptions for gender dysphoria treatment (11/18). Detail: Historical addition referencing California mandates and exceptions for gender dysphoria treatment.

11/19revised

Removed nasal surgery and pectus excavatum sections from medically necessary section in 11/19 (these have InterQual criteria). Detail: Historical operational change removing Nasal Surgery and pectus excavatum (Nuss) sections from medically necessary section since they have InterQual criteria.

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