Mass General Brigham Health Plan reconstructive coverage & PA

Coverage Criteria for Reconstructive and Cosmetic Procedures

inv-01: General reconstructive procedure criteria

Covered when ALL of the following are met

General reconstructive coverage: 1) The medical condition or complication and the functional impairment is well documented by supportive testing and clinical notes (photos may be required); and 2) The requested procedure can be reasonably expected to resolve the medical condition or complication and functional impairment.

Members must meet general coverage criteria and specific procedure criteria when applicable.

inv-02: Trauma to the face — restorative procedure criteria

Facial restorative procedures after accidental trauma are covered when the following are met

Facial trauma restorative criteria: 1) The circumstances of the accidental trauma and degree of injury are well documented by supportive testing and clinical notes (photos may be required); and 2) The procedure must be requested and performed within 18 months of the accidental injury OR for children ≤16 documentation that delaying >18 months was required for growth; and 3) The requested procedure can be reasonably expected to have a successful outcome.18 months for timing; age 16 for pediatric growth consideration

Only the initial restorative procedure will be authorized unless significant functional impairment or ongoing complication remains.

inv-03: Otoplasty specific criteria

Otoplasty is medically necessary for congenital absence of the ear (anotia) or severe (grade III) microtia.

Otoplasty is considered cosmetic for all other indications.

inv-04: Pectus Carinatum surgical repair

Pectus Carinatum surgical repair covered when ALL of the following are met:

Pectus Carinatum repair criteria: 1) The member has a severe chest wall deformity causing (or at risk for causing) cardiovascular or respiratory compromise; and 2) The medical record documents degree of deformity and direct relationship to symptoms including supportive cardiopulmonary testing such as pulmonary function testing; and 3) The member has completed bone growth, generally >= 15 years of age.

inv-05: Pectus Carinatum bracing

Pectus Carinatum bracing covered when ALL of the following are met:

Pectus Carinatum bracing criteria: 1) The member has a severe chest wall deformity causing (or at risk for causing) cardiovascular or respiratory compromise; and 2) The medical record documents degree of deformity and relationship to symptoms including supportive cardiopulmonary testing; and 3) Documentation that member understands and will adhere to bracing protocol (number of hours and length of use); and 4) Evaluation for scoliosis shows no moderate or severe scoliosis (Cobb angle >25 degrees); and 5) Member is a child whose costal cartilage has been assessed as compliant.

Bracing is generally not medically necessary for asymptomatic members; criteria must be met for coverage.

inv-06: Panniculectomy

Panniculectomy medical necessity determined via InterQual criteria; photo documentation required.

Panniculectomy: Medical necessity for panniculectomy of the abdomen is determined through InterQual criteria; photo documentation may be required as part of the determination.

Access InterQual criteria via the provider website.

inv-07: Labiaplasty (labial hypertrophy)

Labiaplasty (labial hypertrophy) — authorization when ALL criteria met

Labiaplasty criteria: 1) Functional deficit that interferes with activities of daily living; and 2) Age >= 18 years; and 3) Documentation of recurrent rashes/ulcers unresponsive to conservative treatment or dyspareunia.

Gender-affirming labiaplasty is addressed under the Gender Affirming Procedures policy.

inv-08: Skin redundancy removal

Removal of redundant skin on arms, legs, buttocks covered when ALL of the following are met

Redundant skin removal: 1) The redundant skin is the result of weight loss of at least 75 pounds that has been stable for at least 6 months (if post-bariatric surgery, member must be >= 12 months post-op); and 2) Written and photographic documentation demonstrates the occlusive redundant skin directly causes symptomatic intertriginous ulcerations or macerations unresponsive to hygiene and optimal physician-supervised treatment for >=6 months, or recurrent bacterial skin infections (>=2 in 12 months) requiring systemic antibiotics.>= 75 pounds; stability >= 6 months (>=12 months post-bariatric)

Required lateral and frontal photos and documentation of infections/ulcerations.

inv-09: Dermabrasion

Dermabrasion — Covered when ANY of the following are met

Dermabrasion criteria: 1) To remove superficial basal cell carcinomas and actinic keratoses when conventional treatments (cryotherapy, curettage, excision, 5-FU) are impractical due to number/distribution of lesions; or 2) For restoration after previous medically necessary surgery.

Dermabrasion medical necessity is determined through a custom InterQual subset.

inv-10: Scar Revision

Scar Revision — Covered when medical necessity is determined via InterQual criteria (photo documentation may be required).

Scar Revision: Medical necessity for scar revision (including keloid revision and fractional laser ablation for burns/traumatic scars) is determined through InterQual; photo documentation may be required.

Use customized InterQual Scar Revision subset where applicable.

inv-11: Poland Syndrome chest wall repair

Poland Syndrome chest wall repair — Covered when ANY of the following are met

Poland Syndrome repair: 1) The member has a chest wall deformity causing functional impairment such as diminished exercise tolerance or respiratory compromise; or 2) The medical record documents chest wall defects in which the chest viscera are exposed and susceptible.

See the Breast Surgeries policy for breast reconstruction guidance in Poland Syndrome.

inv-12: Skin lesion and skin tag removal

Skin lesion and skin tag removal — Covered when documentation demonstrates clinical necessity

Skin lesion removal: Covered when lesion is clinically suspicious for malignancy; a benign lesion that grows/enlarges, begins to bleed or ulcerate, or is frequently irritated; or nevi when rationale is to reduce risk of malignant transformation. Certain common skin procedures do not require prior authorization.

Photo documentation may be required.

Skin tag removal: Covered when the medical record documents size, location, and characteristics of the skin tag and one or more of specified clinical conditions (eg, chronic/recurrent bleeding or intense itching/pain; physical evidence of inflammation such as purulence, oozing, edema, erythema; diagnostic uncertainty with concern for malignancy; obstruction of an orifice or restriction of vision; located in area subject to recurrent trauma with documented trauma; or preauricular tag containing cartilage).

Skin tag removal generally does not require prior authorization; photo documentation may be required.

inv-13: Skin Tag Removal (Medically Necessary Conditions)

Covered when ALL of the following are met

Skin tag coverage

Clinical criteria: One or more of: physical evidence of inflammation (purulence, oozing, edema, erythema); chronic/recurrent/persistent bleeding, intense itching, and/or pain; diagnostic uncertainty where malignancy is a consideration; obstructs an orifice or restricts vision; located in area subject to recurrent trauma with documented trauma; preauricular skin containing cartilage

inv-14: Hemangioma Destruction

Hemangioma Destruction — Covered when medical record documents lesion details and meets InterQual subset criteria

Hemangioma coverage: Medical record clearly documents the size, location, and characteristics of the hemangioma; and at least one of the following is present: functional impairment of vital structures (eg, impaired vision or auditory impact), pedunculated hemangioma, recurrent bleeding/ulceration/infection, or association with Kasabach-Merritt syndrome.

Photo documentation may be required. Actual InterQual Hemangioma Destruction criteria are accessed via the provider website.

inv-15: Port Wine Stain Treatment by Laser

Port Wine Stain Treatment by Laser — Covered when ALL of the following are met

Port wine stain coverage: Medical record clearly documents the size, location, and characteristics of the port wine stain; and at least one of the following: port wine stain on the face or neck, or recurrent bleeding, ulceration, or infection.

Photo documentation may be required. Criteria are detailed in the InterQual Hemangioma/Port Wine Stain subset.

inv-16: Hair Removal

Covered when ANY of the following are met

Hair removal coverage: Treatment is for recurrent hair follicle infections or recurrent infected cysts, or to prevent recurrence after surgical treatment of pilonidal sinus disease; OR is part of gender incongruence treatment in accordance with the Gender Affirming Procedures policy.

Must be performed by a treating licensed provider or board-certified dermatologist.

inv-17: Supernumerary Digit Removal

Covered when ALL of the following are met

Supernumerary digit removal coverage: Member is age 19 years or younger.

Coverage limited to members up to age 19; removal for members over age 19 is excluded.

inv-18: Varicose Vein Ligation/Ablation/Phlebectomy/Sclerotherapy

Covered when medical necessity is established per InterQual criteria

Varicose vein treatment coverage: Medical necessity for varicose vein interventions (ligation/stripping, endovenous ablation, ambulatory phlebectomy, sclerotherapy) is determined using InterQual criteria accessed via the provider website.

Follow InterQual guidance for specific procedure indications and required documentation.

inv-19: MassHealth-specific coverage notes

Coverage and criteria updates and integrations

MassHealth Variations and PA: MassHealth-specific code mappings and reimbursement notes are provided; some endovenous chemical adhesive codes (36482, 36483) are noted as not reimbursed for MassHealth Plans. Prior authorization requirements and the PA code lists were updated and InterQual subsets and customized InterQual criteria were added where necessary.

See the policy code list for reimbursed vs not reimbursed codes and updated PA requirements; access InterQual via the provider website for subset criteria.

Mass General Brigham Health Plan excludes procedures that are performed primarily to improve or enhance appearance; these cosmetic surgeries and non‑surgical cosmetic dermatology procedures are not medically necessary and are not covered. Reconstructive procedures that address a documented functional impairment, ongoing medical complication, or structural abnormality (congenital, traumatic, infectious, neoplastic, or disease‑related) may be covered when the general reconstructive criteria are met, including supportive clinical documentation and, when requested, high‑quality photos.

See General Exclusions for a non‑exhaustive list of procedures and circumstances excluded as cosmetic. Examples include hair transplantation, liposuction, facial and calf implants, skin tightening procedures, chemical peels, laser skin resurfacing, and other procedures where the primary purpose is aesthetic improvement. The policy reiterates that procedures solely to enhance appearance in the absence of functional abnormalities or associated medical complications are not covered.

Male pectoral augmentation performed for the purpose of enhancing chest appearance and not related to covered chest wall repair is excluded from coverage.

For Poland Syndrome chest wall repairs, reconstruction is considered when there is functional impairment or exposed/susceptible chest viscera. Isolated costal aplasia or hypoplasia without demonstrable physical functional impairment is excluded from coverage.

Dermabrasion and other cosmetic dermatologic procedures performed for acne, acne scarring, wrinkles, or uneven pigmentation are not medically necessary and are excluded. When dermabrasion is requested for medical indications (for example, treating numerous superficial basal cell carcinomas or actinic keratoses when conventional therapies are impractical), medical necessity is determined via the custom InterQual subset.

Abdominoplasty is listed as an exclusion and is distinct from panniculectomy. Medical necessity for panniculectomy is determined through InterQual criteria and may require photo documentation; abdominoplasty intended for cosmetic contouring is not covered.

The policy lists representative examples of excluded cosmetic procedures (not exhaustive), including but not limited to: hair transplantation, liposuction, facial and calf implants, skin tightening, chemical peels, and laser skin resurfacing. Inclusion of a procedure in this list generally indicates it is considered cosmetic unless specific criteria elsewhere in the policy state otherwise.

Treatment of congenital capillary hemangiomas that are naturally resolving and are not interfering with a vital structure (for example, the eye or airway), or that do not have documented recurrent infection or significant bleeding requiring intervention, is excluded. Hemangioma destruction for medically significant lesions remains subject to InterQual criteria and required documentation.

Removal of supernumerary digits is covered only for members age 19 years and younger; requests for removal on members over age 19 are excluded and may be denied.

MassHealth variation language notes that endovenous ablation by chemical adhesive (CPT 36482, 36483) is listed as Not Reimbursed for MassHealth Plans. The policy also reiterates that procedures considered cosmetic may be denied as not medically necessary per payer guidance.

Otoplasty is considered medically necessary only for congenital absence of the ear (anotia) or severe (grade III) microtia. For all other indications, otoplasty is considered cosmetic and is not covered except as explicitly stated (for example, associated reconstructive needs).

Pectus carinatum management (bracing or surgical repair) is addressed as a treatment for severe chest wall deformity causing or at risk of causing cardiopulmonary compromise. The policy notes that bracing and surgical repair are generally not medically necessary for asymptomatic individuals, and documents the need for objective demonstration of deformity, cardiopulmonary testing, and other criteria to establish medical necessity.

Cosmetic dermatology procedures performed solely to enhance appearance without signs or symptoms of functional abnormality are excluded. The policy specifically calls out dermabrasion for cosmetic indications (acne scarring, pigmentation, wrinkles) as not covered and reiterates the general exclusion for non‑therapeutic cosmetic procedures.

Requests for procedures that are primarily cosmetic and not medically necessary are at risk for denial. Providers should ensure documentation demonstrates functional impairment or an associated medical complication and should follow updated prior authorization and code list requirements to reduce denial risk.

Coding and Billing Guidance

Not Payable CodesCPTNot Covered

0479T	Not Payable (listed in policy text)
0480T	Not Payable (listed in policy text)

Skin procedure items not requiring prior authorization (descriptions as listed)mixed

Tangential biopsy of skin	single lesion; each additional lesion
Punch biopsy of skin	single lesion; each additional lesion
Excisions and simple closure	benign lesions
Incisional biopsy of skin	single lesion; each additional lesion
Excision	malignant lesions
Injection into skin
Destruction of benign lesion(s)	other than skin tags or cutaneous vascular proliferative lesions

Informational CPT Codes (selected)CPT

15780	Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)
15781	Dermabrasion; segmental, face
15782	Dermabrasion; regional, other than face
15819	Cervicoplasty
15820	15820 (description not fully listed in excerpt)
15821	Blepharoplasty, lower eyelid; with extensive herniated fat pad
15822	Blepharoplasty, upper eyelid
15823	Blepharoplasty, upper eyelid; with excessive skin weighting down lid
15824	Rhytidectomy; forehead (Not covered for MassHealth Plans)
15825	Rhytidectomy; neck with platysmal tightening (platysmal flap) (Not covered for MassHealth Plans)

Additional Informational CPT Codes (selected)CPT

17106	Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm
17107	Destruction of cutaneous vascular proliferative lesions (eg, laser technique)
17108	Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm
17999	Unlisted procedure, skin, mucous membrane and subcutaneous tissue
21120	Genioplasty/augmentation (autograft, allograft, prosthetic material)
30400	Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
30410	Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip
36465	Injection of non-compounded foam sclerosant with ultrasound compression maneuvers; single incompetent extremity
36470	Injection of sclerosant; single incompetent vein (other than telangiectasia)

MassHealth Variation Codesmixed

30220	Insertion, nasal septal prosthesis (button).
30400	Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip.
30410	Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages,and/or elevation of nasal tip.
30420	Rhinoplasty primary; including major septal repair.
30430	Rhinoplasty, secondary; minor revision (small amount of nasal tip work).
30435	Rhinoplasty, secondary; intermediate revision (bony work with osteotomies).
30450	Rhinoplasty secondary; major revision (nasal tip work and osteotomies).
30460	Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only.
30462	Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies.
30465	Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction).

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Required weight loss for redundant skin procedures

Required weight loss>= 75 pounds

ApplicabilityApplies to redundant skin removal of arms, legs, and buttocks (see panniculectomy for abdomen)

Bariatric surgery noteIf weight loss from bariatric surgery, member must be >= 12 months post-op

Stability period after weight loss

Required stability period after weight loss>= 6 months

Photo/documentation requirement

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization required — treating specialist must request prior authorization for reconstructive and cosmetic procedures.

Treating specialist must request prior authorization for reconstructive and cosmetic procedures.

Prior Authorization

InterQual Prior Authorization

InterQual prior authorization — Several procedures require review against InterQual criteria or InterQual custom subsets. Providers must use the InterQual lookup on the Mass General Brigham Health Plan provider website to determine medical necessity for these procedures.

Pectus excavatum and carinatum (InterQual determines medical necessity; Pectus listed as not requiring PA but medical necessity via InterQual)
Panniculectomy (InterQual; photo documentation required)
Dermabrasion (custom InterQual subset)
Scar revision (InterQual/customized subset for fractional laser ablation)

Background and Scope

Reconstructive procedures are covered when they address a documented functional impairment, ongoing medical complication, or structural abnormality due to congenital defects, trauma, disease, or tumors. Coverage requires documentation that the procedure is expected to resolve the medical condition or functional impairment; photos and supportive testing may be required as part of medical necessity review.

Definitions and Terms

Reconstructive — definition

DefinitionReconstructive: procedures needed to improve functioning of a body part, treat an associated medical complication, or otherwise medically necessary even if appearance is improved

Coverage contextCovered when medical condition/functional impairment is documented and procedure expected to resolve impairment

DocumentationSupportive testing and clinical notes required; photos may be required

Cosmetic — definition

DefinitionCosmetic: procedures performed primarily to improve or enhance appearance and excluded as not medically necessary

Exclusion implicationRequests primarily for cosmetic appearance are denied as not medically necessary

OpenPayer

Reconstructive and Cosmetic Procedures — Coverage and Prior Authorization Criteria

Coverage Criteria for Reconstructive and Cosmetic Procedures

Coding and Billing Guidance

Provider Requirements, Prior Authorization, and Documentation

Background and Scope

Definitions and Terms