CurrentIndependent HealthPolicy M020808388

Cosmetic Procedures

Defines medical necessity criteria and coverage stance for cosmetic and reconstructive plastic surgery procedures across Independent Health lines of business, and specifies when procedures considered cosmetic may be authorized.

Policy Summary

PayerIndependent Health

PolicyCosmetic Procedures

Policy CodePolicy M020808388

Change TypeNo material change

Effective Date8/8/2002

Next Review Date

Key ActionObtain prior authorization for cosmetic procedures (exceptions apply) and provide required documentation such as photos and office notes when requesting panniculectomy or rhinoplasty.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

M020808388Policy identifier

Pre-authorization requiredPrior auth stance

MultipleAuthorizable procedures

3Related policies

Coverage Criteria and Medical Necessity

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Initial Authorization Criteria

Covered when ONE or more of the following are met

Coverage pathways

Functional deficit pathway: Functional deficit causes deviation from normal function resulting in significant limitation of ADLs; and Medical Director review documents necessity
Specific procedure indications: See listed procedure-specific criteria (e.g., panniculectomy, rhinoplasty, gynecomastia criteria, chemical peel lesion count and topical therapy failure)
Procedure-specific criteria are detailed in subsequent nodes

Procedure-specific Authorization Criteria

Procedure-specific criteria (examples extracted as explicit rules in the document)

Panniculectomy criteria: If requested following significant weight loss: office notes and photos must document that the panniculus hangs below the level of the pubis; pannus causes persistent or frequently occurring cellulitis, abscess or skin ulceration that has not responded to a trial of at least three months of medical therapy (treatment should include topical antifungals, topical and/or systemic corticosteroids, and/or local or systemic antibiotics); and evidence of stable weight for at least six months. If following bariatric surgery: all of the above AND panniculectomy should not be performed until at least 18 months after bariatric surgery and only when weight has been stable for the most recent six months.>=3 months medical therapy; >=6 months weight stability; >=18 months post-bariatric surgery

Office notes and photos required

Rhinoplasty criteria: Internal nasal deformity must be of a degree which could not be corrected by routine endonasal septoplasty; provide anterior, lateral and submental photos; and meet at least one clinical indication such as nasal airway obstruction or difficulty breathing through the nose, rhinolalia clausa, epistaxis, or an external nasal deformity (e.g., nose off midline, narrow nose, severely bent nose, valvular stenosis) that contributes to the condition.

Pictures (anterior, lateral, submental) required

Gynecomastia correction: All of the following: presence of breast subareolar tissue of at least 2 cm in diameter in the supine male; evaluation by an endocrinologist to rule out reversible cause; and glandular breast tissue is the primary cause documented on physical exam and/or mammography.>=2 cm

Chemical exfoliation for actinic keratoses: All of the following: 15 or more actinic keratoses or other pre-malignant skin lesions present (when impractical to treat each lesion individually); and failure to adequately respond to topical 5‑fluorouracil (5‑FU) or imiquimod unless contraindicated.15 lesions

Used when impractical to treat lesions individually

Procedures that are cosmetic and not medically necessary are not covered. Specifically, panniculectomy is not considered medically necessary when requested solely for correction of poorly fitting clothes, for hygiene issues when no functional deficit exists, for treatment of superficial inflammation or infection that is controlled with topical medications, or solely for correction of low back pain given its typically multifactorial etiology. Pre-authorization is required for these services except where noted elsewhere in the policy.

General exclusions and limitations referenced in this policy align with federal and state guidance. See CMS Medicare Benefit Policy Manual Chapter 16 - General Exclusions from Coverage; 120 Cosmetic Surgery and applicable New York State Medicaid provider guidance for additional exclusions, coverage limits, and administrative requirements. Payment for covered services remains subject to member eligibility, contract exclusions, and any limitations in the member's contract at the time services are rendered.

Cosmetic procedures performed solely to improve appearance are considered not medically necessary and are excluded from coverage. Medicare Advantage explicitly excludes cosmetic surgery and related expenses except for prompt repair after accidental injury or surgery intended to improve the function of a malformed body part. Providers should confirm whether a requested procedure meets medical necessity or reconstructive criteria before proceeding with authorization or billing.

Coding and Conservative Therapy Thresholds

Conservative therapy and lesion counts

Chemical exfoliation (actinic keratoses)Requires 15 or more lesions present AND failure to adequately respond to topical 5-FU or imiquimod unless contraindicated

Dermabrasion for actinic keratoses/removalCovered when conventional removal methods (cryotherapy, curettage, excision) are impractical due to number/distribution of lesions

Pannus-related surgery conservative therapyPannus must have failed a trial of at least three months of medical therapy (topical antifungals, topical/systemic corticosteroids, and/or antibiotics)

Pannus weight stability requirementEvidence that the individual has maintained stable weight for at least six months prior to panniculectomy; if post-bariatric surgery, wait at least 18 months after surgery

General conservative therapy ruleWhere topical therapies are standard, failure of topical 5-FU or imiquimod is required prior to procedures like chemical peel or dermabrasion unless contraindicated

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required

Pre-authorization is required for cosmetic procedures unless otherwise noted below. Skin tag removal is exempt from the pre-authorization requirement and may be subject to retrospective review. Pre-authorization for select gender affirming procedures for MediSource, MediSource Connect, and Essential Plan is not required — see the Gender Affirming Treatment policy (Policy No. M20151112001). Providers must verify member eligibility and contract terms at the time of service; payment for covered services remains subject to eligibility, contract exclusions, and limitations in the member's contract.

Pre-authorization required for cosmetic procedures except skin tag removal and select gender affirming procedures for certain plans.
Skin tag removal is exempt from pre-authorization and may be reviewed retrospectively.
Pre-authorization not required for select gender affirming procedures for MediSource, MediSource Connect, and Essential Plan — see Policy No. M20151112001.
Providers should confirm member eligibility and contract terms at time of service; payment is subject to contract limitations.

Note

Prior Authorization Implied by Medical Necessity

Medical necessity criteria in this policy determine coverage and imply prior authorization requirements when applicable. Providers must ensure requests meet the documented medical necessity criteria in the policy before submission.

This policy contains medical necessity criteria that apply for this service.
Prior authorization requirements are implied by the policy's medical necessity criteria.

Documentation Required

Conservative Therapy Trial Required

When conservative topical therapies are standard (for example, actinic keratoses), documentation must show failure of topical 5-fluorouracil (5-FU) or imiquimod unless there is a documented contraindication.

Failure of a trial of 5-FU (Efudex) or imiquimod (Aldara) is required unless contraindicated prior to procedures for actinic keratoses.
Document conservative therapy trials in the medical record prior to procedural authorization requests.

Documentation Required

Panniculectomy Documentation Requirements

For panniculectomy requests following significant weight loss (including after bariatric surgery), office notes and photographs from appropriate providers must document that the panniculus hangs below the pubis, that the pannus causes persistent or recurrent cellulitis, abscess, or skin ulceration unresponsive to at least three months of medical therapy, and that weight has been stable for the required period (at least six months; if post-bariatric surgery, panniculectomy should not be performed until at least 18 months after bariatric surgery). Panniculectomy is not medically necessary when performed solely for poorly fitting clothes, hygiene problems without functional deficit, superficial inflammation/infection controllable with topical medicines, or solely for low back pain.

Office notes and anterior/lateral/submental photos are required where specified (e.g., rhinoplasty requires photos; panniculectomy requires photos documenting panniculus position).
Panniculus must hang below level of the pubis.
Pannus must cause persistent/frequent cellulitis, abscess, or skin ulceration not responsive to ≥3 months of medical therapy (topical antifungals, topical/systemic corticosteroids, and/or antibiotics).
Evidence of stable weight for ≥6 months is required; if weight loss due to bariatric surgery, wait ≥18 months after surgery and weight stability for the most recent 6 months.

Documentation Required

Rhinoplasty Documentation Requirements

Rhinoplasty requests for functional nasal deformity must document that the internal nasal deformity cannot be corrected by routine endonasal septoplasty, include anterior, lateral, and submental photographs, and demonstrate functional findings such as nasal airway obstruction, rhinolalia clausa, epistaxis, or an external deformity contributing to the condition.

Internal nasal deformity must be of a degree not correctable by routine endonasal septoplasty.
Photos required: anterior, lateral, and submental views.
Documentation must show one or more functional indications (nasal airway obstruction, rhinolalia clausa, epistaxis, or qualifying external nasal deformity).

Denial Risk

Coverage Exclusion for Cosmetic-Only Procedures

Cosmetic procedures and related expenses are not covered when performed solely to improve appearance. Procedures are covered only when medically necessary as reconstructive surgery incidental to or following surgery for trauma, infection, or other disease of the involved body part. Providers should apply the Medicare Advantage and other plan-specific exclusions and criteria when submitting requests.

Cosmetic surgery is excluded when for appearance improvement only; exceptions include prompt repair after accidental injury or improvement of function of a malformed body part.
For MediSource, MediSource Connect, and Essential Plan, procedures only for cosmetic purposes are not payable unless medically necessary for reconstruction after trauma, infection, or disease.
Apply plan-specific coverage exclusions and contract terms at time of service.

Note

Coverage Subject to Member Contract

Payment for covered services remains subject to member eligibility, contract exclusions, and limitations in the member's contract at the time services are rendered. Providers must verify eligibility and benefits and confirm any pre-authorization requirements prior to service.

Verify member eligibility and contract terms at time of service.
Payment remains subject to contract exclusions and limitations.

Background and Policy Scope

Coverage decisions distinguish among cosmetic, reconstructive, and medically necessary procedures. Interventions performed primarily to improve appearance are generally excluded unless there is a documented functional deficit, a reconstructive indication (including prompt repair of accidental injury), or other listed clinical criteria that justify treatment. Case-by-case review, including Medical Director review, may be used to determine medical necessity when functional impairment is claimed.

Key Definitions

Functional deficit (or impairment)

DefinitionA limitation 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 (ADLs).

Context of useUsed to determine when a procedure is medically necessary (functional deficit pathway requires medical director review)

Assessment implicationRequests based on functional deficit are reviewed by the Medical Director on a case-by-case basis

Panniculectomy

DefinitionSurgical 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.

Medical therapy requirementPannus must have not responded to at least three months of medical therapy including topical antifungals, topical and/or systemic corticosteroids, and/or local or systemic antibiotics

Documentation and timingIf requested after bariatric surgery, office notes and photos must document panniculus hangs below pubis; wait at least 18 months after bariatric surgery and weight stable for at least the most recent six months

Cosmetic surgery or services

DefinitionProcedures performed to improve the member's appearance and self-esteem.

Coverage implicationCosmetic procedures performed solely to improve appearance are not medically necessary and are excluded from coverage (exceptions apply when functional deficit or reconstructive need documented)

ExamplesIncludes procedures such as facelifts, rhinoplasty for purely aesthetic reasons, and other interventions intended primarily for appearance enhancement

ASPS ICC - Gynecomastia

Reference titleASPS Recommended Insurance Coverage Criteria for Third-Party Payers: Gynecomastia

Source detailsAmerican Society of Plastic Surgeons (ASPS) web site; March 2002; Reaffirmed June 2015; accessed January 27, 2026

PurposeCited as a non-regulatory reference to inform gynecomastia coverage criteria in this policy

Policy Summary

PayerIndependent Health

PolicyCosmetic Procedures

Policy CodePolicy M020808388

Change TypeNo material change

Effective Date8/8/2002

Next Review Date

Key ActionObtain prior authorization for cosmetic procedures (exceptions apply) and provide required documentation such as photos and office notes when requesting panniculectomy or rhinoplasty.

SourceLink

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