CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Plastic Surgery (Cosmetic vs Reconstructive) Coverage Policy

Defines prior authorization, medical necessity criteria, covered and excluded plastic surgery procedures for multiple Neighborhood Health Plan of Rhode Island lines of business including Medicaid, CHIP, Medicaid expansion, Medicare Advantage, and commercial products. Applies skin lesion removal criteria and general reconstructive indications; refers to CMS guidance for Medicare Advantage members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPlastic Surgery (Cosmetic vs Reconstructive) Coverage Policy

Policy CodePolicy N/A

Change TypeRevised (review history updated)

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and submit medical necessity documentation; note biopsies for lesions suspicious for malignancy do not require authorization.

SourceLink

POLICY UPDATE CHANGES

Policy was reinstated in March 2022 after being archived in 2018 and has multiple review and revision dates with the latest entries in 2024 and 2025.

MultipleCovered Indications

SeveralExplicit Exclusions

AnnualReview Frequency

Coverage Summary

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Scope: This policy applies to multiple Neighborhood Health Plan of Rhode Island lines of business including Medicaid (RiteCare, Substitute Care, Children with Special Needs, Rhody Health Partners, Rhody Health Expansion), Health Benefit Exchange, Medicare Advantage, and commercial products. It defines prior authorization and medical necessity criteria for plastic surgery procedures and applies specific criteria for skin lesion removal and general reconstructive indications.

Coverage stance: Mixed — many reconstructive procedures are covered when medical necessity criteria are met and prior authorization is obtained, while clearly cosmetic procedures and specified exclusions are not covered.

Top-level distinction: Cosmetic surgery (procedures performed solely to enhance appearance) is considered not medically necessary and is excluded. Reconstructive surgery (procedures to repair, restore, or improve body parts to correct abnormal structures or improve function) is considered medically necessary when documented criteria are met.

Medical-Necessity Criteria

General Coverage Determination

Plastic surgery is considered medically necessary when ALL of the following are met:

ALL of the following

At least one of the following conditions is met
- Repair of severe disfigurement resulting from a disease, an injury, or a non-cosmetic medical procedure.
- Repair of disfigurement resulting from a congenital anomaly that interferes with function or causes gross disfigurement compared with normal.
- Breast reconstruction surgery following mastectomy, including all stages of reconstruction of the breast on which the mastectomy has been performed, as well as surgery and reconstruction of the other breast to produce a symmetrical appearance.
- Surgery as treatment for scars that cause pain, functional limitation, or are medically symptomatic.
- Other procedures to relieve problems associated with difficulty in activities of daily living.
Documentation indicates that conservative measures have been tried and failed.
Prior authorization
- Prior authorization and review of medical necessity documentation is required.

Note: Additional criteria may be utilized, including national and community standards of practice.

Operational note

Skin Lesion (Benign) Coverage Criteria

Covered when AT LEAST ONE of the following conditions is met:

ANY of the following

The lesion has evidence of inflammation (purulence, edema, or erythema).
The lesion is clinically suspicious for malignancy.
The lesion demonstrates sudden enlargement over one month, bleeding, ulceration, intense pain, or intense itching.
The lesion restricts vision or obstructs a body orifice.
The lesion is in an anatomical position that has been subject to recurrent trauma and there is evidence that such trauma has occurred.

Not Covered / Exclusions

Explicit exclusions: The policy expressly lists the following categories as not covered: experimental procedures or treatments, cosmetic surgery, and rhinoplasty.

Other specified not-covered items include revision of scars when performed purely for cosmetic reasons or when the scar resulted from a non-covered surgery or body piercing, and treatment of scarring resulting from acne (considered cosmetic).

These exclusion categories are explicit and should be treated as not covered regardless of other considerations unless otherwise noted in applicable benefit language.

Coding

Covered surgical CPT codesCPTCovered

ALL	All current surgical CPT codes other than those determined to be exclusions or not medically necessary upon review of submitted documentation

Exclusions / Not CoveredmixedNot Covered

EXCLUDED

Experimental procedures or treatments, cosmetic surgery, rhinoplasty, revision of scars when purely cosmetic or when scar is result of a non-covered surgery or body piercing; treatment of scarring resulting from acne

Billing Rule

Coding reference

Reference the Authorization Quick Reference Guide available via Neighborhood's provider resources for coding details. Surgical CPT codes are eligible for coverage unless they are specifically determined to be exclusions or not medically necessary upon review of submitted documentation.

Provider Actions & Authorization

Prior Authorization

Prior authorization required

Prior authorization and review of medical necessity documentation is required for plastic surgery procedures. Exception: biopsies of skin lesions that are considered suspicious for malignancy do NOT require authorization.

Documentation Required

Conservative measures documentation

Providers must document that conservative measures have been tried and failed as part of the medical necessity evaluation for plastic surgery procedures.

Documentation Required

Skin lesion justification

For removal of benign skin lesions, providers must document at least one of the following qualifying conditions: evidence of inflammation (purulence, edema, or erythema); clinical suspicion for malignancy; sudden enlargement over one month, bleeding, ulceration, intense pain, or itching; restriction of vision or obstruction of a body orifice; or lesion located in an anatomical position subject to recurrent trauma with evidence that such trauma has occurred.

Background & Definitions

Plastic surgery is defined as the branch of surgery concerned with the repair, restoration, or improvement of injured, defective, or misshapen parts of the body, chiefly by transfer of tissue.

Cosmetic versus reconstructive: surgery performed solely to enhance physical appearance is considered cosmetic and not covered in the absence of medical necessity; reconstructive surgery is performed on abnormal structures caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease, generally to improve function and possibly appearance.

Medicare Advantage determinations: For Medicare Advantage members, Neighborhood follows CMS guidance — applicable payment policies, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs), and other CMS published guidance. If CMS guidance is absent or incomplete, Neighborhood will apply coverage guidance from the Rhode Island Executive Office of Health & Human Services (EOHHS), peer-reviewed scientific evidence such as InterQual, or internal clinical policies as secondary references.

Cosmetic surgery: Per the American Society of Plastic Surgeons and policy text, performed to reshape normal structures of the body in order to improve the patient's appearance and self‑esteem.

Reconstructive surgery: Per policy text, performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease; it is generally performed to improve function and may also be done to approximate a normal appearance.

Revision History

2018archived

Policy was archived in 2018.

03/16/22reinstated

Policy reinstated in March 2022 after being archived in 2018.

03/08/23review

Policy review conducted on 03/08/23.

04/10/24review

Policy review conducted on 04/10/24.

04/09/25review_and_effectiveLatest

Latest review on 04/09/25 with effective entry 04/09/25.