Currentmeridian_health_plan_of_michiganPolicy MI.CP.MP.31

Cosmetic and Reconstructive Procedures

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Defines medical necessity criteria and coding guidance for reconstructive and cosmetic surgical procedures when no procedure-specific criteria exist; applies to Meridian Health Plan of Michigan members and providers submitting coverage requests.

Policy Summary

Payermeridian_health_plan_of_michigan

PolicyCosmetic and Reconstructive Procedures

Policy CodePolicy MI.CP.MP.31

Change TypeNo material changes noted in extracted content

Effective Date

Next Review Date

Key ActionObtain prior authorization for listed CPT and HCPCS codes and document medical necessity per policy and applicable state requirements.

SourceLink

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Currentmeridian_health_plan_of_michiganPolicy MI.CP.MP.31

Cosmetic and Reconstructive Procedures

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Policy Summary

Payermeridian_health_plan_of_michigan

PolicyCosmetic and Reconstructive Procedures

Policy CodePolicy MI.CP.MP.31

Change TypeNo material changes noted in extracted content

Effective Date

Next Review Date

Key ActionObtain prior authorization for listed CPT and HCPCS codes and document medical necessity per policy and applicable state requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

I-IIPolicy sections

~100+Covered CPT/HCPCS codes (partial)

YesAligned with MDHHS manual

23+Bibliographic refs

Coverage Criteria — Reconstructive vs Cosmetic

Reconstructive — Medically Necessary

Reconstructive procedures are considered medically necessary when meeting ONE of the intent criteria below.

Reconstructive intent criteria: 1) The procedure is performed to improve the function of an abnormal body part caused by illness, trauma, or a congenital defect after failure of conservative therapy (unless conservative therapy is not standard of care for the condition, or is contraindicated); 2) Skin tag removal when located in an area that affects eyesight or in an area of friction with documentation of repeated irritation and bleeding; 3) Scar/keloid revision or removal when accompanied by pain unresponsive to conservative therapy and is recurrently infected, unstable, friable, or associated with functional impairment; 4) The medical or functional condition interferes with performance of job duties; 5) The medical or functional condition causes significant disability or psychological trauma (as documented by a psychiatric evaluation).N/A

Any one criterion being met is sufficient for reconstructive medical necessity.

Cosmetic — Not Medically Necessary

Cosmetic surgery is not medically necessary and generally not covered when performed to improve a patient's normal appearance and self-esteem; examples include:

Examples of not medically necessary cosmetic procedures: Excision of excessive skin and subcutaneous tissue (eg, panniculectomy, body lift) performed solely for appearance; body contouring procedures including liposuction (except for removal of lipoma per clinical determination); breast augmentation and augmentation mammoplasty for cosmetic reasons; revision, removal, or replacement of breast implants placed for cosmetic reasons; surgery to correct unsatisfactory results from previous cosmetic or non-covered services; facial augmentation for cosmetic purposes; abdominoplasty; dermabrasion and skin resurfacing for cosmetic purposes; electrolysis/laser hair removal and hair transplantation not performed for permanent hair loss due to disease or injury; tattooing performed for cosmetic reasons (excluding medically indicated post-mastectomy tattooing); injectable fillers for cosmetic enhancement; circumcision revisions solely to improve appearance; mastopexy when not related to reconstruction after mastectomy; correction of inverted nipples for cosmetic reasons; repair of diastasis recti for cosmetic reasons; breast reconstruction for benign lesions only when not otherwise meeting medical necessity criteria.

General coverage framework

Coverage applies when procedures meet MDHHS Provider Manual criteria and medical necessity determinations consistent with this clinical policy and applicable state and federal requirements.

Policy application: Procedures are subject to the MDHHS Provider Manual criteria and medical necessity review; providers must follow state Medicaid provisions when they conflict with this clinical policy. For Medicare members, applicable NCDs, LCDs and Medicare Coverage Articles should be reviewed to ensure consistency with Medicare coverage determinations.

Policy created to align with MDHHS Provider Manual criteria; state Medicaid manual takes precedence over this policy when conflicts exist.

The following procedures are considered cosmetic and are generally not covered when performed solely to improve a patient’s normal appearance and self‑esteem: excision of excessive skin; body contouring; body lift; breast augmentation; liposuction (excluding lipoma per clinical decision support); surgery to correct unsatisfactory results from previous cosmetic or non‑covered services; revision, removal, or replacement of breast implants placed for cosmetic reasons; removal of excess skin after weight loss when solely cosmetic; facial augmentation; abdominoplasty; dermabrasion; skin rejuvenation and resurfacing; electrolysis and laser hair removal; hair transplantation not to correct permanent hair loss from disease or injury; tattooing (except post‑mastectomy reconstruction); injectable fillers; circumcision revisions done only to improve appearance; mastopexy except when part of medically necessary reconstruction post‑mastectomy or other qualifying breast surgery; correction of inverted nipples; repair of diastasis recti; and breast reconstruction for benign lesions unless deemed medically necessary per clinical decision support criteria.

For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Providers should refer to the applicable state Medicaid manual for definitive coverage rules.

It is the policy of Meridian Health Plan of Michigan that cosmetic surgery performed to improve normal appearance and self‑esteem is not medically necessary and is generally not a covered benefit.

Coverage under this clinical policy is guided by medical necessity determinations. Providers are expected to exercise professional medical judgment and document clinical findings that support medical necessity. Procedures performed solely to improve appearance or self‑esteem without clinical indications risk denial as not medically necessary.

Coding and Code Lists

CPT Codes That Support Coverage CriteriaCPT

11200	Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions
11400-11406	Excision, benign lesion including margins, trunk/arms/legs; diameter ranges
11420-11426	Excision, benign lesion including margins, scalp/neck/hands/feet/genitalia; diameter ranges
11440-11446	Excision, other benign lesion including margins, face/ears/eyelids/nose/lips/mucous membrane; diameter ranges
11920-11922	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; area ranges
15772-15775	Grafting of autologous fat harvested by liposuction technique; face/trunk/other sites; injectate volume ranges
15773-15793	Chemical peels and related procedures (facial and nonfacial); various codes
15830-15879	Excision of excessive skin and subcutaneous tissue (panniculectomy/lipectomy) and suction assisted lipectomy codes
15220-15221	Full thickness graft, free, including direct closure of donor site; size increments
17110-17111	Destruction of benign lesions other than skin tags; up to 14 lesions or more

1–10 of 13

1/2

Covered CPT Codes (listed in policy)CPTCovered

19371	Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents
19396	Revision of reconstructed breast (eg, significant removal of tissue, advancement and/or re-inset of flaps or significant capsular revision combined with soft tissue excision in implant-based reconstruction)
19499	Preparation of moulage for custom breast implant; Unlisted procedure, breast
21120	Genioplasty; augmentation (autograft, allograft, prosthetic material)
21121	Genioplasty; sliding osteotomy, single piece
21122	Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin)
21123	Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)
21137	Reduction forehead; contouring only
21138	Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft)
21139	Reduction forehead; contouring and setback of anterior frontal sinus wall; reconstruction midface, LeFort III with forehead

1–10 of 41

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HCPCS CodesHCPCSCovered

G0429	Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) as a result of highly active antiretroviral therapy
Q2026	Injection, Radiesse, 0.1 ml
Q2028	Injection, Sculptra, 0.5 mg

inv-11: Tattooing area / Fat graft injectate / Graft sizes

Tattooing area - smallCode 11920: tattooing intradermal pigments to correct color defects; area 6.0 sq cm or less

Tattooing area - mediumCode 11921: tattooing intradermal pigments to correct color defects; area 6.1 to 20.0 sq cm

Tattooing area - additionalCode 11922: tattooing; each additional 20.0 sq cm (list separately in addition to primary procedure)

Autologous fat graft - small injectateCode 15773/15774: grafting of autologous fat to face/eyelids/mouth/neck/ears/orbits/genitalia/hands/feet; 25 cc or less injectate (15773/15774 variants per anatomic site)

Autologous fat graft - additional injectateCode 15788: each additional 25 cc injectate, or part thereof (list separately in addition to primary procedure)

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior authorization and coding guidance

Prior authorization is implied by the policy’s coding guidance and providers should confirm coding and authorization requirements before claim submission.

Codes referenced in this clinical policy are for informational purposes only; inclusion/exclusion of codes does not guarantee coverage.
Providers should reference the most up-to-date professional coding guidance prior to submission.

Prior Authorization

Obtain prior authorization for listed CPT/HCPCS codes

Prior authorization is required for the procedures and HCPCS/CPT codes enumerated in the policy; submit authorization requests referencing the listed codes.

Examples of listed CPT codes include 19371, 19396, 19499, 21120–21123, 21137–21139, 21159–21160, 21230–21296, 61550–61559.
HCPCS codes listed include G0429, Q2026, Q2028.

Background and Scope

Reconstructive surgery addresses abnormal body structures that result from congenital defects, trauma, surgery, infection, tumors, or disease and is generally intended to restore or improve function and, when appropriate, appearance. Reconstructive procedures are considered medically necessary when they meet the policy’s intent criteria (for example: to improve function of an abnormal body part after failure of conservative therapy, to address scars or keloids with associated pain or functional impairment, or to treat conditions that substantially interfere with work or activities of daily living). Documentation of functional impairment, failed conservative therapy (when applicable), and relevant clinical findings should be provided to support medical necessity determinations.

Definitions

inv-21: Functional impairment

DefinitionFunctional impairment: a health condition in which the normal function of a part of the body or organ system is less than age appropriate at full capacity, variably impacting activities of daily living (eg, decreased range of motion, diminished eyesight or hearing)

Relevance to medical necessityProcedures intended to improve function of an abnormal body part caused by illness, trauma, or congenital defect may be considered medically necessary when functional impairment is present and conservative therapy has failed (unless not standard of care or contraindicated)

Documentation expectationMedical records should document the nature and degree of functional impairment and prior conservative treatments attempted to support a medical necessity determination

Policy Summary

Payermeridian_health_plan_of_michigan

PolicyCosmetic and Reconstructive Procedures

Policy CodePolicy MI.CP.MP.31

Change TypeNo material changes noted in extracted content

Effective Date

Next Review Date

Key ActionObtain prior authorization for listed CPT and HCPCS codes and document medical necessity per policy and applicable state requirements.

SourceLink

On This Page

Full-thickness skin graft sizing

Codes 15220–15221: full-thickness grafts including direct closure of donor site; 20 sq cm or less and each additional 20 sq cm (list separately)

Step Therapy

Conservative therapy prerequisite for reconstructive procedures

Document and demonstrate failure of conservative therapy prior to reconstructive procedures unless conservative therapy is not the standard of care or is contraindicated.

The policy states reconstructive procedures require prior failure of conservative therapy unless not standard of care or contraindicated.

Step Therapy

Step therapy requirements not specified

No specific step therapy protocols are defined in the policy excerpt; follow the conservative therapy prerequisite above and any plan-specific step therapy programs.

The extracted sections do not specify additional step therapy sequences beyond conservative therapy failure.

Documentation Required

Provide photographs if requested

Photographic documentation may be requested to support medical necessity determinations; provide clinical photographs when applicable.

Note in policy: "Photographs may be requested, if applicable."

Documentation Required

Documentation to support medical necessity

Keep complete clinical documentation that supports medical necessity and aligns with this clinical policy and applicable state/federal requirements; providers must exercise professional medical judgment.

Documentation should support the reconstructive intent criteria (eg, functional impairment, failed conservative therapy, recurrent infection, pain).
Follow applicable state Medicaid and Medicare NCD/LCD requirements when documenting and requesting coverage decisions.

Denial Risk

Avoid claims for solely cosmetic procedures (denial risk)

Do not submit claims for procedures performed solely to improve normal appearance or self‑esteem; such cosmetic procedures are considered not medically necessary and risk denial.

Policy lists examples considered cosmetic and not medically necessary (eg, breast augmentation, liposuction, abdominoplasty, injectable filler, tattooing except post‑mastectomy).
Claims for purely cosmetic services may be denied as not medically necessary.

Denial Risk

Follow state Medicaid provisions; they take precedence

For Medicaid members, state Medicaid coverage rules override this clinical policy when they conflict; verify and follow the state Medicaid manual to avoid denials.

Policy note: "when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence."
Check the applicable state Medicaid manual before submitting authorizations/claims for Medicaid members.