InterQual criteria required for coverage

Many reconstructive procedures (for example: brow & eyelid surgery, breast implants, breast reconstruction, breast reduction, orthognathic surgery, rhinoplasty/septoplasty) are covered only when InterQual® criteria are met; obtain prior authorization as required by the member's contract and include documentation demonstrating InterQual criteria are satisfied.

• InterQual criteria apply to Brow & Eyelid Surgery, Breast Implants, Breast Reconstruction, Breast Reduction, Orthognathic Surgery, and other listed procedures.
• Providers must supply documentation to show InterQual criteria are met when requesting authorization.

Inpatient pre-authorization

All inpatient admissions require pre-authorization; failure to obtain inpatient pre-authorization may lead to retrospective review or denial.

• Note in coding disclaimer: “All inpatient admissions require pre-authorization.”

Reference listed CPT codes on prior authorization requests

When requesting prior authorization, reference the CPT procedure codes listed in the policy (see coding sections) to identify the service(s) being requested.

• The policy lists numerous CPT codes (e.g., 15829, 19325, 21110, 21142, 21210) that should be cited on authorization requests.
• Inclusion of a CPT code in the list is informational and does not guarantee coverage; verify member benefits.

Prior authorization may apply to listed CPT codes

Prior authorization may be required by plan rules when billing any of the numerous CPT procedure codes enumerated in the coding module; check plan-specific authorization requirements before performing surgery.

• The document lists many CPT procedure codes governed by this policy and states prior authorization may be required per plan rules.
• Confirm requirements with the member's benefit plan.

No step therapy details in document excerpt

The policy excerpt does not specify any step therapy requirements for cosmetic or reconstructive procedures in this portion of the document.

• No step therapy details are included in the provided sections.

Provide clinical documentation when cosmetic vs reconstructive is unclear

When it is unclear whether a procedure is primarily cosmetic or reconstructive, provide clinical documentation including the history and physical exam, pathology report (if applicable), and preoperative photographs so the Plan can determine classification.

• Documentation will be medically reviewed to determine whether the procedure is primarily reconstructive or cosmetic.
• Include history & physical, pathology report, and preoperative photographs in the authorization/claim submission.

Audits and monitoring may occur

Adherence to the policy may be monitored through post-payment data analysis and/or medical review audits; maintain complete documentation to support medical necessity.

• The coding disclaimer states: “Adherence to the provisions in this policy may be monitored and addressed through post payment data analysis and/or medical review audits.”

Document policy identifiers from header

Reference the policy Procedure Number (CMS03.12), Effective Date (04/01/2026), and Approval Date (01/20/2026) shown in the header when corresponding about or submitting documentation related to this policy version.

• Procedure Number = CMS03.12; Effective Date = 04/01/2026; Approval Date = 01/20/2026.

Include policy number and dates on submissions

Include the policy procedure number (CMS03.12), effective date (04/01/2026), and approval date (01/20/2026) on submissions to align with this policy version.

• Policy header identifies Procedure Number = CMS03.12 and dates to reference on submissions.

Insufficient documentation may trigger denial

If a procedure that has both cosmetic and reconstructive components lacks adequate clinical documentation (history, physical, pathology, preoperative photos) to demonstrate primarily reconstructive intent, the Plan will medically review and may deny the claim as primarily cosmetic.

• The Plan will medically review procedures with mixed cosmetic/reconstructive components and may deny if primarily cosmetic.
• Adequate documentation must be submitted to support reconstructive intent.

Pre-authorization required for inpatient admissions

Inpatient admissions performed without pre-authorization may be subject to denial or retrospective review by the Plan.

• “All inpatient admissions require pre-authorization.”
• Failure to pre-authorize may result in review or denial.

Cosmetic procedures may be denied as not medically necessary

Coverage may be denied when procedures billed are cosmetic rather than reconstructive; many CPT codes listed in the policy correspond to services that could be classified as cosmetic and are subject to coverage review.

• The policy lists numerous CPT codes for cosmetic/reconstructive services and notes coverage denials could be triggered when procedures are cosmetic in nature.
• Verify clinical indications and submit supporting documentation.

Removed topics may require referral to other policies

Items removed from this policy (Keloid Treatment, Sclerotherapy link to CMS22.01, Tattoo Removal link to CMS16.02) were noted in the revision history; refer to respective policies or guidance for coverage and authorization requirements for those services.

• Revision history: Removed 'Keloid Treatment' and links for Sclerotherapy and Tattoo Removal from CMS03.12.
• Refer to the specific policies referenced in the revision history for those services.