ModifiedMass General Brigham Health PlanPolicy 051

Medical Necessity Guidelines — Reconstructive and Cosmetic Procedures

Guidelines for determining medical appropriateness, prior authorization requirements, and coverage criteria for reconstructive and cosmetic surgical procedures for Mass General Brigham Health Plan members across product lines.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Necessity Guidelines — Reconstructive and Cosmetic Procedures

Policy CodePolicy 051

Change TypeReformatPA table updatesadded exclusion

Effective Date

Next Review Date

Key ActionTreating specialist must request prior authorization for reconstructive and cosmetic procedures and follow updated PA requirements in the policy tables for specific codes and member types.

SourceLink

POLICY UPDATE CHANGES

Reformatted policy and removed references to retired InterQual subsets; clarified criteria hierarchy for One Care and SCO variation.

Added exclusion regarding scalp cooling to prevent hair loss.

Updated prior authorization table and added variation for One Care and SCO members.

1policy document (this part)

24+Medicare Advantage PA codes listed

18 mofacial trauma time limit

YesPrior auth for Commercial/QHP

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InterQualInterQual referenced

Coverage Criteria for Reconstructive and Cosmetic Procedures

Skin Redundancy: removal on arms, legs, and buttocks

Mass General Brigham Health Plan covers medically necessary removal of redundant skin when criteria 1 and 2 are met:

ALL of the following

The redundant skin is the result of weight loss of at least 75 pounds that has been stable for at least 6 months, and if the weight loss occurs as a result of bariatric surgery, the member must be at least 12 months post bariatric surgery.
- ANY of the following
  - Symptomatic intertriginous ulcerations or macerations that are unresponsive to good personal hygiene and well documented optimal physician-supervised local treatment and that continually persist for a period of at least six months despite this care and treatment. Required lateral and frontal photos must demonstrate a significantly redundant and occlusive skin fold, and additional photos must document the presence of intertriginous skin ulceration and maceration.
  - Recurrent bacterial skin infections (at least 2 in a 12-month period) directly related to the redundant skin, which required systemic antibiotics. Required lateral and frontal photos must demonstrate a significantly redundant and occlusive skin fold.

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Port Wine Stain Treatment by Laser

Mass General Brigham Health Plan covers medically necessary port wine stain treatment by laser for members who meet both of the following criteria:

ALL of the following

The medical record clearly documents the size, location, and characteristics of the port wine stain (photo documentation may be required).
ANY of the following
- The port wine stain is on the face and neck.
- The port wine stain has recurrent bleeding, ulceration, or infection.

Coding, Codes Requiring Prior Authorization, and Procedure Codes

Prior authorization required codes (Medicare Advantage / One Care / SCO)CPT

15780	listed in prior authorization codes
15781	listed in prior authorization codes
15782	listed in prior authorization codes
15820	listed in prior authorization codes
15821	listed in prior authorization codes
15822	listed in prior authorization codes
15823	listed in prior authorization codes
15830	listed in prior authorization codes
17106	listed in prior authorization codes
17107	listed in prior authorization codes

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Procedure CPT codes (selection)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	Blepharoplasty, lower eyelid.
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.
15825	Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap).

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Additional procedure and venous treatment CPT codesCPT

17106	Destruction of cutaneous vascular proliferative lesions; less than 10 sq cm.
17107	Destruction of cutaneous vascular proliferative lesions; 10.0 to 50.0 sq cm.
17108	Destruction of cutaneous vascular proliferative lesions; over 50.0 sq cm.
17999	Unlisted procedure, skin, mucous membrane and subcutaneous tissue.
21120	Genioplasty; augmentation (autograft, allograft, prosthetic material).
21121	Genioplasty; sliding osteotomy, single piece.
21122	Genioplasty; sliding osteotomies, 2 or more osteotomies.
21123	Genioplasty; sliding, augmentation with interpositional bone grafts.
21125	Augmentation, mandibular body or angle; prosthetic material.
21127	Augmentation, mandibular body or angle; with bone graft, onlay or interpositional.

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Venous, eyelid and reconstructive CPT codes (continued)CPT

36473	Endovenous ablation therapy of incompetent vein, extremity, mechanochemical; first vein treated.
36474	Endovenous ablation therapy; mechanochemical; subsequent vein(s) treated in a single extremity.
36475	Endovenous ablation therapy; radiofrequency; first vein treated.
36476	Endovenous ablation therapy; radiofrequency; subsequent vein(s) treated in a single extremity.
36479	Endovenous ablation therapy; laser; first vein treated.
36482	Endovenous ablation therapy by transcatheter delivery of a chemical adhesive; first vein treated.
36483	Endovenous ablation therapy by transcatheter delivery of a chemical adhesive; subsequent vein(s) treated.
37700	Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions.
37718	Ligation, division, and stripping, short saphenous vein.
37722	Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below.

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Additional reconstructive and orthotic codesCPT | HCPCS

69300	Otoplasty, protruding ear, with or without size reduction.
0479T	Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first 100 cm2 or part thereof, or 1% of body surface area of infants and children.
0480T	Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area of infants and children.
L1320	Thoracic pectus carinatum orthosis, sternal compression, rigid circumferential frame with anterior and posterior rigid pads, custom fabricated.

Facial trauma restorative procedure timing — Requested and performed within 18 months of the accidental injury (exceptions documented)

Timing requirementProcedure must be requested and performed within 18 months of the accidental injury (exceptions documented).

Pediatric exceptionFor children ≤16, medical record must document that delay >18 months was required for growth to be complete.

Other documented delaysFor delays >18 months (adults), record must document that postponement was required for optimal reconstruction, healing, or remodeling.

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

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required for Commercial/QHP

Prior authorization requirements vary by product line. For Commercial and QHP lines the treating specialist must request prior authorization for reconstructive and cosmetic procedures. Failure to obtain required prior authorization for listed procedure codes may affect reimbursement and can result in denial of payment.

Commercial/QHP: Prior authorization required (treating specialist must request).
Failure to obtain prior authorization may affect reimbursement/coverage.

Prior Authorization

Medicare Advantage prior authorization — Prior authorization required only for the listed codes

Medicare Advantage members require prior authorization only for the specific CPT/HCPCS codes listed below. Medical necessity determinations for Medicare Advantage follow CMS guidance (NCDs, LCDs, LCAs, and Medicare manuals); when CMS guidance is unavailable, the plan's medical policies are used.

PA required only for: 15780, 15781, 15782, 15820, 15821, 15822, 15823, 15830, 17106, 17107, 17108, 21120, 21121, 21123, 30420, 30435, 30450, 36465, 36466, 36470, 36471, 36473, 36474, 36482, 36483, 0479T, 0480T.

Background and Scope

Reconstructive procedures are covered when they are needed to improve function, treat an associated medical complication, or correct structural alterations resulting from congenital defects, trauma, infection, tumors, or disease. Coverage requires adequate documentation of the medical condition, functional impairment, and the expectation that the procedure will resolve the impairment; photographic documentation may be required.

Definitions and Key Terms

Reconstructive surgery definition — Surgery needed to improve functioning or treat complications even if appearance improves

DefinitionSurgery needed to improve the functioning of a body part, treat an associated medical complication, or otherwise medically necessary even if appearance is improved.

Coverage basisReconstructive procedures covered when physical functional impairment or ongoing medical complication is documented and expected to improve with the procedure.

DocumentationMedical condition, functional impairment, and supportive testing and clinical notes must be well documented; photos may be required.

Cosmetic surgery definition — Surgery performed primarily to improve or enhance appearance; excluded from coverage

DefinitionSurgery or procedures performed primarily to improve or enhance appearance; excluded from coverage as not medically necessary.

Policy Revision History and Key Changes

2026-03reform_and_clarifyLatest

Ad hoc review: reformatted policy, removed references to retired InterQual subsets for dermabrasion/hemangioma/port wine stain, and clarified criteria hierarchy for One Care and SCO variations.

2026-01annual_update

Annual review: updated prior authorization table and added variation for One Care and SCO members; added LCDs to Medicare variation and hyperlinks to related medical policies; formatting fixes.

2025-09

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Necessity Guidelines — Reconstructive and Cosmetic Procedures

Policy CodePolicy 051

Change TypeReformatPA table updatesadded exclusion

Effective Date

Next Review Date

Key ActionTreating specialist must request prior authorization for reconstructive and cosmetic procedures and follow updated PA requirements in the policy tables for specific codes and member types.

SourceLink

On This Page

Age for chest wall surgical repair — Generally >= 15 years

Minimum age guidelineMember has completed bone growth, generally ≥ 15 years of age.

Clinical requirementSurgical repair covered when severe chest wall deformity is causing or at risk for cardiovascular or respiratory compromise.

Documentation neededMedical record must document degree of deformity and direct relationship to symptoms, including supportive cardiopulmonary testing.

Weight loss requirement for redundant skin removal — >= 75 pounds lost, stable for at least 6 months (>=12 months post-bariatric surgery)

Weight loss threshold>= 75 pounds of weight loss prior to consideration for redundant skin removal.

Stability requirementWeight loss must have been stable for at least 6 months; if after bariatric surgery, member must be ≥ 12 months post‑surgery.

Clinical consequencesRedundant skin must directly cause symptomatic intertriginous ulcerations/macerations persisting ≥ 6 months despite optimal care, OR recurrent bacterial skin infections (≥2 in 12 months) requiring systemic antibiotics.

Photo documentationRequired lateral and frontal photos must demonstrate significantly redundant occlusive skin fold and document lesions or infections.

Trauma to face timing — Time requirement historically changed from 12 months to 18 months

Current time requirementProcedure must be requested and performed within 18 months of the accidental injury.

Historical changePolicy notes the time requirement was changed from 12 months to 18 months in prior revision history.

Documentation for delaysFor delays beyond the time limit, documentation must state reasons (children ≤16 growth completion or other rationale for postponement).

CMS guidance (NCD/LCD/LCA) directs medical necessity for Medicare Advantage; see policy for links.

Prior Authorization

One Care / SCO prior authorization — Prior authorization required only for the listed codes for One Care and SCO members.

One Care and Senior Care Options (SCO) members require prior authorization only for the specific codes listed below. Medical necessity follows CMS guidance; if Medicare Advantage criteria are not met or guidance is unavailable, MassHealth criteria are applied per the policy hierarchy.

PA required only for: 15780, 15781, 15782, 15820, 15821, 15822, 15823, 15830, 17106, 17107, 17108, 21120, 21121, 21123, 30420, 30435, 30450, 36465, 36466, 36470, 36471, 36473, 36474, 36482, 36483, 0479T, 0480T.
Hierarchy: Medicare Advantage criteria -> MassHealth criteria when Medicare criteria are not met or guidance unavailable.

Prior Authorization

Pectus Excavatum — prior auth — Prior authorization is not required for pectus excavatum surgical repair; medical necessity is determined using InterQual criteria.

Pectus excavatum surgical repair does not require prior authorization; however, medical necessity for the procedure is determined using InterQual® criteria accessed via the plan's provider website.

Pectus excavatum repair: Prior authorization not required.
Medical necessity determined using InterQual® criteria (access via MassGeneralBrighamHealthPlan.org).

Prior Authorization

InterQual® required for many procedures — Medical necessity for many reconstructive facial and abdominal procedures is determined through InterQual® criteria accessed via the payer.

Medical necessity for many reconstructive facial, abdominal, scar, and varicose vein procedures is determined through InterQual® criteria. Providers must use the payer's portal to access the specific InterQual® subsets referenced in this policy.

InterQual® required for: Blepharoplasty (visual field and non-visual), Brow ptosis repair, Rhinoplasty, Septoplasty, Panniculectomy, Scar revision, Varicose vein treatments.
Access InterQual® via the Mass General Brigham Health Plan provider website (InterQual® Criteria Lookup).

Note

Prior authorization exemptions for common skin procedures — Tangential, punch, incisional biopsies (single lesion) and excisions/simple closure for benign or malignant lesions, injections, and destruction often do not require prior authorization.

Certain common skin procedures and simple biopsies/excisions do not require prior authorization. Examples include tangential, punch, and incisional biopsies (single lesion), excisions and simple closure of benign lesions, excision of malignant lesions, injections into skin, and destruction of some benign lesions.

No PA required for: Tangential biopsy (single lesion), Punch biopsy (single lesion), Incisional biopsy (single lesion), Excisions and simple closure (benign lesions), Excision (malignant lesions), Injection into skin, Destruction of some benign lesions.
Skin tag removal does not require prior authorization when documentation supports medical necessity.

Documentation Required

Required clinical and photo documentation — Medical record must include written and photographic documentation for redundant skin; photos may be required for skin lesion removal.

Photo and clinical documentation requirements are strict for many procedures. The medical record must document the medical condition, functional impairment, and supportive testing; photos may be required and in some cases must be emailed or mailed for clarity. Examples: panniculectomy requires photo documentation; redundant skin removal requires written and photographic documentation demonstrating occlusive redundant folds and complications; skin lesion removal may require photos.

Documentation must include medical condition, functional impairment, and supportive testing/clinical notes; photos may be required and could need to be emailed/mailed.
Panniculectomy: photo documentation required.
Redundant skin removal: required lateral and frontal photos and additional photos documenting ulceration or infection when claimed.

Billing Rule

Bundled procedure billing — Liposuction is often integral to skin removal surgery and is not separately reimbursed; billing separately may affect claims.

Billing note: liposuction is often considered integral to removal of excessive skin and is not separately reimbursed; billing liposuction separately when integral to a covered skin removal procedure may affect claims.

Liposuction during skin removal is usually bundled with skin removal surgery and not separately reimbursed.

Note

Code list informational notice — Code list is provided for informational purposes only; inclusion does not imply coverage or reimbursement.

Code inclusion disclaimer: The policy lists procedure codes for informational purposes only. Inclusion of a code does not imply coverage or reimbursement; verify coverage and PA requirements before billing.

Codes provided in policy are informational only; inclusion does not constitute coverage or reimbursement.

Documentation Required

Conservative therapy requirement for dermabrasion — Dermabrasion coverage requires that conventional treatments are impractical due to number/distribution or lesion characteristics.

Dermabrasion coverage requires conservative therapy criteria: conventional treatments (cryotherapy, curettage, excision, 5‑FU) must be impractical due to the number/distribution of lesions, or the procedure must be for restoration after prior medically necessary surgery.

Conservative therapy requirement: cryotherapy, curettage, excision, and 5‑FU must be impractical due to lesion number/distribution for dermabrasion to be covered.

Note

References and policy updates — References section lists bibliographic references; does not specify provider documentation or authorization steps.

Policy notes and references: The policy's references section provides bibliographic sources that support clinical guidance; it does not prescribe operational authorization steps or specific denial criteria. The policy history documents updates to prior authorization tables, code lists, One Care/SCO variations, and InterQual® usage. No step therapy requirements are listed in the references or policy.

References supply clinical citations and do not specify provider documentation or authorization steps.
Policy history: updated PA table, One Care/SCO variations, InterQual® additions; see Effective Dates/Revision History.
No step therapy requirements are included in the policy or references.

Denial Risk

Exclusions may cause denial — Procedures excluded (e.g., male pectoral augmentation unrelated to covered chest wall repair) and general exclusions may trigger denial.

Exclusions and denial risk: Procedures performed solely for cosmetic purposes or primarily to enhance appearance in the absence of functional signs/symptoms are excluded and may be denied. Specific exclusions include hair transplantation, liposuction (when cosmetic), facial/calf implants, chemical peels, laser resurfacing, and others listed in General Exclusions.

Cosmetic-only procedures without signs/symptoms of functional abnormality are not covered and may be denied.
Examples of excluded procedures: hair transplantation, liposuction (cosmetic), facial implants, chemical peels, laser skin resurfacing, scalp cooling caps.

Cosmetic procedures are considered not medically necessary unless specifically noted otherwise in coverage criteria.

Examples excludedIncludes procedures where primary purpose is aesthetic enhancement (e.g., hair transplantation, liposuction, facial implants, chemical peels, laser resurfacing).

Otoplasty — medically necessary definition (anotia, severe microtia)

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

Cosmetic designationOtoplasty is considered cosmetic (not medically necessary) for all other indications.

Redundant skin definition — Excess skin after >=75 lb weight loss, stable >=6 months (12 months post-bariatric)

DefinitionRedundant skin: excess skin resulting from weight loss of at least 75 pounds that has been stable for at least 6 months (≥12 months post‑bariatric surgery if applicable).

Clinical consequence requirementMust cause symptomatic intertriginous ulcerations/macerations unresponsive to optimal care for ≥6 months, or recurrent bacterial infections (≥2 in 12 months) related to the redundant skin.

DocumentationWritten and photographic documentation (lateral and frontal photos) required to demonstrate occlusive folds and associated lesions or infections.

Cosmetic procedure definition — Procedures solely to enhance appearance without functional signs/symptoms; not covered

DefinitionProcedures performed solely to enhance a patient’s appearance in the absence of signs or symptoms of functional abnormalities; considered not covered unless specifically noted otherwise.

ScopeApplies to non‑surgical cosmetic dermatology procedures as well as surgical procedures where aesthetic enhancement is primary purpose.

Reference to policyCosmetic procedure exclusions are listed under General Exclusions and apply unless an exception is specified in coverage criteria.

Lipedema — referenced literature and guideline citations for lipedema diagnosis and treatment

Referenced literatureOkhovat JP, Alavi A. Lipedema: A Review of the Literature. Int J Low Extrem Wounds. 2015;14(3):262-7.

Guideline citationReich‑Schupke S, Schmeller W, Brauer WJ, et al. S1 guidelines: Lipedema. J Dtsch Dermatol Ges. 2017;15(7):758-767.

Additional referencesHayes Inc. Evidence Analysis Research Brief: Liposuction for the Treatment of Lipedema (2019) and other surgical treatment reviews cited in references.

Varicose veins / chronic venous disease — referenced guidelines and reviews for endovenous ablation and sclerotherapy

Key guidelineGloviczki P, Comerota AJ, Dalsing MC, et al. Society for Vascular Surgery/American Venous Forum clinical practice guidelines for care of patients with varicose veins and chronic venous diseases (J Vasc Surg. 2011).

Systematic reviewsCochrane and other systematic reviews on endovenous ablation, foam sclerotherapy, and conventional surgery for saphenous varices are cited (e.g., Nesbitt et al.; Murad et al.).

Additional evidenceRandomized trials and comparative studies of endovenous laser, radiofrequency, foam sclerotherapy, and surgical stripping are referenced (e.g., Rasmussen et al.).

Ad hoc review: corrected typos, removed customized varicose veins InterQual subset and retired MassHealth varicose veins guidance link, and updated related policies and code disclaimer.

2025-07coding_update

Ad hoc review: updated prior authorization table and code list.

2025-03annual_review

Annual review: added InterQual subset references and customized InterQual criteria where necessary; added bracing criteria and code for pectus carinatum brace; updated skin biopsy PA exemptions; removed liposuction exclusion for lipedema; added exclusion for scalp cooling caps to prevent hair loss; updated references.

2024-10ad_hoc_update

Ad hoc review: added MassHealth variation, removed other references to MassHealth elsewhere in the policy, and updated codes.

2024-01annual_review

Annual review: added criteria for otoplasty and added bracing to pectus carinatum criteria; updated codes.

2023-02annual_review

Annual review: added Medicare Advantage to the prior authorization table on page 1.