CurrentIndependent HealthPolicy M020808388

Cosmetic Procedures

Defines medical necessity criteria, coverage stance, and authorization requirements for cosmetic and reconstructive plastic surgery procedures across Independent Health lines of business; affects providers requesting authorization for cosmetic/reconstructive procedures.

Policy Summary

PayerIndependent Health

PolicyCosmetic Procedures

Policy CodePolicy M020808388

Change TypeNo material changes

Effective DateAug 8, 2002

Next Review Date

Key ActionObtain pre-authorization for cosmetic procedures (skin tag removal is exempt).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Pre-authorization requiredprocedures generally require prior authorization

Multiple linesApplies to multiple product lines

Examples listedClinical indications include ~30 named procedures/conditions

PublicData classification

Coverage Criteria and Policy Scope

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Covered with documented medical necessity or reconstructive indication

Covered when ANY of the following apply:

Contract rider: Member's contract contains a cosmetic rider

If cosmetic rider present, procedure may be covered

Functional deficit: A functional deficit that causes deviation from the normal function of a tissue or organ resulting in significantly limited, impaired, or delayed capacity to perform physical activities of daily living; these requests are reviewed by the Medical Director on a case-by-case basis

Functional deficit must be documented; additional procedure-specific criteria apply

Procedure-specific indications

Abdominoplasty (including 'tummy tuck' or belt lipectomy) when related to ventral hernia repair
Acne surgery (extraction, triamcinolone injections, extraction of milia) for therapeutic treatment of acne lesions
Alopecia areata treatment: Treatment for alopecia areata (may include intralesional or topical corticosteroids; extensive disease may include short systemic glucocorticoid courses)
Augmentation mammoplasty in conjunction with a cancer diagnosis or as part of gender dysphoria treatment
See Gender Reassignment Treatment policy for gender-related requests
Breast asymmetry correction when associated with cancer diagnosis or congenital absence of breast (e.g., Poland's Syndrome)
Breast implant removal in conjunction with a cancer diagnosis or for a ruptured prosthesis causing a functional deficit
Chemical exfoliation/chemical peel for actinic keratoses and/or other premalignant lesions when ALL of the following are met: 15 or more lesions and failure to adequately respond to topical 5-FU or imiquimod unless contraindicated
Failure of topical therapy required unless contraindicated
Collagen implants (fat or silicone injections) to correct a functional deficit resulting from a medical condition
Dermabrasion (conventional dermaplaning or CO2 laser) for removal of superficial basal cell carcinomas and precancerous actinic keratoses when ALL of the following are met: conventional methods (cryotherapy, curettage, excision) are impractical due to number/distribution of lesions AND member has failed a trial of 5-FU or imiquimod unless contraindicated
Failure of topical therapy required unless contraindicated; conventional methods must be impractical
Destruction of vascular proliferative lesions: Destruction/treatment (including laser) of congenital port-wine stains and hemangiomas
Earlobe repair for trauma (e.g., accidental injury, dog bite)
Genioplasty for jaw and/or cranio-facial deformities
Gynecomastia correction when ALL of the following are met: presence of subareolar tissue ≥2 cm in diameter in the supine male; endocrinology evaluation to rule out reversible causes; glandular breast tissue is primary cause (documented by exam and/or mammography)
Endocrinology evaluation and documentation required
Labiaplasty to alleviate injury, trauma, or chronic irritation after conservative measures have failed
Conservative treatment must have failed
Liposuction (lipectomy): Liposuction for treatment of lipomas, gynecomastia, pseudogynecomastia, lipodystrophy, or axillary hyperhidrosis
Mastopexy (breast lift) for post-mastectomy or partial mastectomy patients (considered medically appropriate per NY State Law)
Otoplasty (revision or reconstruction of the ear)
Panniculectomy when ONE of the following sets of conditions are met: (A) If requested following significant weight loss: office notes and photos document panniculus hangs below pubis, pannus causes persistent or frequent cellulitis/abscess/skin ulceration unresponsive to ≥3 months medical therapy, and evidence of stable weight for ≥6 months; if weight loss followed bariatric surgery, panniculectomy must be delayed ≥18 months after bariatric surgery and weight stable for most recent 6 months
Medical therapy trial must include topical antifungals, topical/systemic corticosteroids, and/or local/systemic antibiotics; photographic and office documentation required
Rhinoplasty for functional nasal deformity when ALL of the following are met: internal nasal deformity not correctable by routine endonasal septoplasty; pictures required (anterior, lateral, submental); and request documents one or more of: nasal airway obstruction/difficulty breathing, rhinolalia clausa, epistaxis, or external nasal deformity contributing to condition (nose off midline, narrow nose, severely bent nose, valvular stenosis)
Photographs required (anterior, lateral, submental)
Rhytidectomy (facelift) when indicated to correct a documented functional deficit from facial nerve palsy
Scar revision via surgery or intralesional steroid injection for symptomatic or functionally limiting scars
Skin tag excision when tags are located in areas subject to repeated irritation and bleeding
Telangiectasis: Treatment of telangiectasis (e.g., photoablation, laser, sclerosing injections, UV therapy) for rosacea when there is a documented functional deficit
Testicular implant in conjunction with cancer diagnosis or following traumatic removal of testicles

Provider Requirements, Authorization & Documentation

Prior Authorization

Prior Authorization Required

Pre-authorization is required for most procedures in this policy. Exceptions: skin tag removal is exempt from pre-authorization and may be subject to retrospective review. Pre-authorization for select gender reassignment procedures for MediSource, MediSource Connect, and Essential Plan is not required per the Gender Dysphoria Treatment policy (Policy No. M20151112001).

Skin tag removal exempt from pre-authorization (may be retrospectively reviewed)
See Gender Dysphoria Treatment policy M20151112001 for exceptions in certain products

Documentation Required

Rhinoplasty Documentation Required

Requests for rhinoplasty for functional nasal deformity must include photographic documentation. Submit an anterior view, lateral view and submental view to support the request.

Photos required: anterior, lateral, and submental views

Documentation Required

Panniculectomy — Post-Weight-Loss Documentation

When panniculectomy is requested following significant weight loss or bariatric surgery, provide office notes and photos from appropriate providers documenting the panniculus and clinical course. Documentation must show the panniculus hangs below the pubis, evidence of persistent/recurrent cellulitis/abscess/skin ulceration unresponsive to at least three months of medical therapy, and stable weight for at least six months. If related to bariatric surgery, panniculectomy should not be performed until at least 18 months after bariatric surgery.

Documentation must show panniculus hangs below the level of the pubis
Evidence of persistent or recurrent cellulitis/abscess/ulceration unresponsive to ≥3 months medical therapy (topical antifungals, topical/systemic corticosteroids, and/or antibiotics)
Evidence of stable weight for ≥6 months
If post-bariatric surgery, wait ≥18 months after surgery before panniculectomy

Documentation Required

Chemical Exfoliation / Dermabrasion Requirements

For chemical exfoliation or dermabrasion for actinic keratoses or superficial lesions, medical necessity requires either 15 or more lesions (making individual lesion treatment impractical) or failure to adequately respond to topical therapy with 5‑fluorouracil (5‑FU) or imiquimod, unless contraindicated. Conventional removal methods must be impractical due to number/distribution of lesions when dermabrasion is used.

Indication: ≥15 lesions or impractical to treat individually
Require failure of topical 5‑FU or imiquimod unless contraindicated
Conventional methods (cryotherapy, curettage, excision) must be impractical for dermabrasion

Note

Medical Necessity Criteria Apply

This policy contains medical necessity criteria that apply to covered services. Determination of coverage is subject to those medical necessity criteria.

Note

Payment Subject to Eligibility, Contract Exclusions and Limitations

Payment for covered services is subject to member eligibility at the time of service, the member's contract terms, and any exclusions or limitations stated in the contract.

Note

Version Control and Approval Signature

Maintain version control and approval signatures on file. The document revision history and approval signature should be retained as part of the policy record.

Signature/approval on file required (indicate Yes/No)
Retain revision history and owner/notes for each revision

Denial Risk

Cosmetic Procedures and Product Notes

Requests for cosmetic procedures that are not medically necessary may be denied. Product-specific rules apply: Commercial/self-funded plans may cover cosmetic procedures only if a cosmetic rider exists; Medicare Advantage and certain state products generally do not cover cosmetic surgery except in limited circumstances.

Commercial/Self-Funded: Cosmetic procedures covered only if contract includes a cosmetic rider; functional deficit determinations reviewed by Medical Director
Medicare Advantage: Cosmetic surgery not covered except for prompt repair of accidental injury or to improve function of a malformed body member
MediSource/MediSource Connect/Essential Plan: Cosmetic procedures not covered unless medically necessary for reconstruction following trauma, infection, or disease

Denial Risk

Not Covered — Cosmetic Procedures

Requests that are cosmetic and not medically necessary are not covered. Panniculectomy is not considered medically necessary when performed solely for poorly fitting clothes, hygiene issues without functional deficit, treatment of superficial inflammation controllable with topical medicines, or solely for low back pain.

Cosmetic, not medically necessary procedures are not covered
Panniculectomy exclusions: solely for clothing fit, hygiene, superficial inflammation treatable with topical meds, or solely for low back pain

Note

Provider Documentation — Additional Notes

Provider-action placeholder: ensure all provider documentation supports the requested procedure per the clinical indications and include any additional supporting clinical evidence when applicable.

Key Definitions

Functional Deficit

DefinitionA deficit that causes deviation from the normal function of a tissue or organ which results in a significantly limited, impaired, or delayed capacity to perform physical activities of daily living.

Clinical implicationFunctional deficits are reviewed case-by-case by the Medical Director when determining medical necessity for reconstructive or cosmetic procedures.

Documentation requiredRequests must document how the deficit significantly limits activities of daily living to meet medical necessity criteria.

Panniculectomy

DefinitionPanniculectomy is a surgical procedure to remove a large flap or apron (panniculus) of redundant skin and subcutaneous fat that hangs down from the abdomen covering the pubis and groin.

Common indicationsPerformed for redundant panniculus that contributes to recurrent skin infection, ulceration, or functional impairment when conservative care has failed.

Timing after weight lossPolicy notes that panniculectomy should not be performed until appropriate postoperative/stability intervals are met (e.g., documentation of stable weight; if post-bariatric, surgery should be at least 18 months after weight-loss surgery).

Alopecia areata

DefinitionAlopecia areata is a chronic, relapsing, immune-mediated inflammatory disorder affecting hair follicles resulting in nonscarring hair loss.

Disease courseCharacterized by relapsing episodes of hair loss; inflammatory process targets hair follicles without scarring.

Coverage relevanceListed as a defined condition in the policy's clinical context; management and procedure coverage depend on documented medical necessity per policy criteria.

ASPS gynecomastia guidance

ReferenceASPS Recommended Insurance Coverage Criteria for Third-Party Payers: Gynecomastia (American Society of Plastic Surgeons).

PurposeServes as clinical guidance cited by the policy to inform coverage decisions for gynecomastia correction.

AvailabilityDocumented as a non-regulatory reference with the ASPS position statement accessible via the ASPS website (referenced March 2002; reaffirmed June 2015).

Version and Revision History

2025-08-01formatting_revisionLatest

Document revised for formatting; signature/approval on file (Owner: Health Care Services).

2025-03-01review_no_change

Document reviewed by Health Care Services; no revisions made.

2024-03-01review

Document reviewed by Health Care Services.

2024-01-01revision

Document revised by Health Care Services.

2023-03-01review

Document reviewed by Health Care Services.

2022-03-01revision

Document revised by Health Care Services.

2021-04-01review

Document reviewed by Health Care Services.

2020-05-01revision

Document revised by Health Care Services.

2019-06-01revision