ModifiedOklahoma Health Care AuthorityPolicy N/A

Cosmetic and Reconstructive Procedures

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This OHCA guideline establishes medical-necessity and prior-authorization requirements for cosmetic and reconstructive surgical procedures for Oklahoma Medicaid fee-for-service members and providers.

Policy Summary

PayerOklahoma Health Care Authority

PolicyCosmetic and Reconstructive Procedures

Policy CodePolicy N/A

Change TypeModified

Effective DateMarch 25, 2025

Last ReviewMar 10, 2025

Next Review DateMarch 1, 2028

Key ActionObtain prior authorization for the listed procedures and submit documentation supporting medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

119CPT codes requiring prior authorization

3Reconstructive coverage pathways

6Required documentation elements

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ModifiedOklahoma Health Care AuthorityPolicy N/A

Cosmetic and Reconstructive Procedures

Customize your policy alerts

Sign up for all Oklahoma Health Care Authority policy alerts

Know when Oklahoma Health Care Authority releases new policies or updates existing guidance.

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This OHCA guideline establishes medical-necessity and prior-authorization requirements for cosmetic and reconstructive surgical procedures for Oklahoma Medicaid fee-for-service members and providers.

Policy Summary

PayerOklahoma Health Care Authority

PolicyCosmetic and Reconstructive Procedures

Policy CodePolicy N/A

Change TypeModified

Effective DateMarch 25, 2025

Last ReviewMar 10, 2025

Next Review DateMarch 1, 2028

Key ActionObtain prior authorization for the listed procedures and submit documentation supporting medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

119CPT codes requiring prior authorization

3Reconstructive coverage pathways

6Required documentation elements

21+Cosmetic coverage exclusion age

0-20Pediatric cosmetic age range

Coverage Criteria

Reconstructive Surgery

Reconstructive surgery may be considered for coverage when the procedure meets at least ONE of the following criteria. The information listed under prior authorization documentation must be submitted with each request to determine medical necessity.

Coverage and documentation requirements

ONE of the following
- Improves or restores physical function.
- Corrects significant deformity resulting from disease, trauma, or a previous therapeutic process.
- Corrects congenital or developmental anomalies that have resulted in significant functional impairment or disfigurement.
Prior authorization documentation
- The location and cause of the defect must be documented.
- The medical reasons for the procedure must be documented.
- Pre-surgery medical photographs of the defect must be submitted.
- The CPT codes describing the procedures to be performed must be listed.
- Symptoms of pain or infection must be documented.
- The function that will be improved or restored must be documented.

Some reconstructive procedures have additional medical coverage criteria in separate OHCA guidelines, including breast procedures, eye procedures, labiaplasty, panniculectomy, rhinoplasty, sclerotherapy, and septoplasty.

Additional OHCA guidelines may apply.

Cosmetic Procedures — Members Age 0–20

For members aged 0–20 years, cosmetic procedures may be considered for coverage when ALL of the following requirements are met.

ALL of the following

The member has a diagnosis classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM).
A treating physician provides documentation certifying that the procedure is emotionally necessary.

All requests must be referred to an OHCA Medical Director or Physician Consultant for review.

Referral is required for every request.

Cosmetic Procedures — Members Age 21 and Older

Cosmetic procedures are not covered for members aged 21 years and older.

Procedures performed for cosmetic reasons are not a covered benefit for members aged 21 years and older.

Not covered.

For members aged 21 years and older, the cosmetic-procedure coverage exclusion applies: procedures performed for cosmetic reasons are not a covered benefit.

Coding and Age Parameters

Covered CPT CodesCPTCovered

11920	CPT code listed as covered requiring prior authorization
11921	CPT code listed as covered requiring prior authorization
11922	CPT code listed as covered requiring prior authorization
11950	CPT code listed as covered requiring prior authorization
11951	CPT code listed as covered requiring prior authorization
11952	CPT code listed as covered requiring prior authorization
11954	CPT code listed as covered requiring prior authorization
11960	CPT code listed as covered requiring prior authorization
11970	CPT code listed as covered requiring prior authorization
14301	CPT code listed as covered requiring prior authorization

1–10 of 113

1/12

Adult cosmetic-procedure age threshold

Age threshold21 years and older

Coverage statusProcedures performed for cosmetic reasons are not a covered benefit.

Applies toMembers aged 21 years and older requesting procedures for cosmetic reasons.

Pediatric cosmetic-procedure age range

Age range0-20 years

Coverage considerationCosmetic procedures may be considered for coverage.

Additional requirements

Provider Submission Requirements

Prior Authorization

Prior Authorization Required for Listed CPT Codes

Prior authorization is required for the listed covered CPT procedures. Reconstructive-surgery requests must also include the documentation needed to establish medical necessity.

Policy Background

The guideline distinguishes reconstructive surgery, which restores or improves physical function or corrects deformities and abnormal structures caused by congenital or developmental abnormalities, trauma, infection, tumors, disease, or other significant conditions, from cosmetic surgery, which reshapes normal body structures primarily to improve appearance or self-esteem. Reconstructive coverage is evaluated based on functional impairment, significant deformity, or disfigurement. Cosmetic coverage is age-dependent: procedures for members aged 21 years and older are not covered, while procedures for members aged 0–20 years may be considered only with the required diagnosis, treating-physician certification of emotional necessity, and review by an OHCA Medical Director or Physician Consultant.

Key Definitions

Acquired condition or deformity

DefinitionA medically diagnosed condition or deformity that occurs after birth and significantly deviates from the common structure or function of the body.

Possible causesTrauma, infection, tumor, or disease.

ExamplesBurn wounds, lacerations, growths, and problems associated with aging.

Congenital abnormality

DefinitionA medically diagnosed condition present at or from birth that significantly deviates from the common structure or function of the body.

Possible causesA hereditary or developmental disability or disease.

Examples

Policy Summary

PayerOklahoma Health Care Authority

PolicyCosmetic and Reconstructive Procedures

Policy CodePolicy N/A

Change TypeModified

Effective DateMarch 25, 2025

Last ReviewMar 10, 2025

Next Review DateMarch 1, 2028

Key ActionObtain prior authorization for the listed procedures and submit documentation supporting medical necessity.

SourceLink

On This Page

The member must have a DSM-classified diagnosis and documentation from a treating physician certifying that the procedure is emotionally necessary.

Prior Authorization

Medical Director Review: Members Age 0–20

Refer every cosmetic-procedure request for a member age 0 through 20 to an OHCA Medical Director or Physician Consultant for review.

Apply this review requirement to all pediatric cosmetic requests, including requests submitted for emotional necessity.

Documentation Required

Required Reconstructive-Surgery Documentation

Submit all of the following with each reconstructive-surgery prior authorization request so OHCA can determine medical necessity.

Location and cause of the defect.
Medical reasons for the procedure.
Pre-surgery medical photographs of the defect.
CPT codes describing the procedures to be performed.
Documentation of symptoms of pain or infection.
Documentation of the function that will be improved or restored.

Documentation Required

Additional Documentation for Members Age 0–20

For a cosmetic request for a member age 0 through 20, submit the additional documentation required for consideration of coverage.

A diagnosis classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM).
Certification from the treating physician that the procedure is emotionally necessary.
Refer the request to an OHCA Medical Director or Physician Consultant for review.

Denial Risk

Cosmetic Procedures Age 21 and Older: Not Covered

Procedures performed for cosmetic reasons for members age 21 and older are not a covered benefit.

Do not submit cosmetic-only procedures for coverage under this benefit.

Note

Reconstructive Medical-Necessity Requirement

Reconstructive surgery may be considered medically necessary when the procedure meets at least one of the following requirements.

Improves or restores physical function.
Corrects a significant deformity resulting from disease, trauma, or a previous therapeutic process.
Corrects a congenital or developmental anomaly that has resulted in significant functional impairment or disfigurement.

Birthmarks, cleft lip and palate deformities, syndactyly, extra or absent fingers, and abnormal breast development such as Poland's Syndrome.

Cosmetic procedure/surgery

DefinitionA surgical procedure performed to reshape and adjust normal structures of the body.

Primary purposeTo improve the patient's appearance and self-esteem.

IntentCosmetic surgery is intended primarily to preserve or improve appearance.

Reconstructive procedure/surgery

DefinitionA surgical procedure performed to restore and improve function and correct deformities or abnormal structures of the body.

PurposeTo restore or improve function and correct deformities or abnormal structures.

Possible causes addressedCongenital defects, developmental abnormalities, trauma, infection, tumors, or disease.