ModifiedPriority Health MedicarePolicy 197

Cosmetic and Reconstructive Surgery

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This policy governs billing, coding, documentation, medical necessity, and reimbursement for cosmetic and reconstructive surgery services for Priority Health Medicare. Cosmetic procedures performed solely to improve appearance are generally not reimbursable, while reconstructive procedures may be reimbursed when medically necessary to restore function or correct abnormalities.

Policy Summary

PayerPriority Health Medicare

PolicyCosmetic and Reconstructive Surgery

Policy CodePolicy N/A

Change TypeModified

Effective DateMay 28, 2026

Next Review DateAugust 2026

Key ActionSubmit documentation and diagnosis coding that establish reconstructive intent, functional impairment, and medical necessity; report all applicable diagnoses and supporting diagnoses when applicable.

SourceLink

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ModifiedPriority Health MedicarePolicy 197

Cosmetic and Reconstructive Surgery

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Policy Summary

PayerPriority Health Medicare

PolicyCosmetic and Reconstructive Surgery

Policy CodePolicy N/A

Change TypeModified

Effective DateMay 28, 2026

Next Review DateAugust 2026

SourceLink

POLICY UPDATE CHANGES

The policy added a list of CPT codes that may be reviewed for approval.

The policy added a requirement that claims include diagnosis coding supporting medical necessity in accordance with CMS LCA requirements.

3ICD-10 codes explicitly identified as excluding coverage

24CPT procedures generally cosmetic and potentially non-covered

2Primary service categories addressed

6 monthsMinimum treatment or stable-weight period

Grade III or IVRequired gynecomastia severity

8Pages in policy document

Coverage and Medical Necessity Criteria

Cosmetic and reconstructive surgery coverage criteria

Coverage may be available when the procedure is reconstructive and medically necessary; cosmetic services performed only to improve appearance are not reimbursable.

Coverage outcome

Covered with criteria when
- The procedure restores function or corrects an abnormality caused by a birth condition, injury, or disease.
- The medical record supports reconstructive intent, functional impairment, and medical necessity.
- The claim includes appropriate diagnosis coding and all applicable supporting diagnoses.
Not covered when
- The procedure is performed only to improve appearance without affecting function.
Denial risk when
- Documentation does not support reconstructive intent or functional impairment.
- Diagnosis coding does not support medical necessity or required diagnosis information is missing.

For applicable Medicare indications

If the indication does not meet the criteria of an applicable NCD, local LCD, or specific medical policy, a Pre-Service Organization Determination (PSOD) must be completed.

Breast reduction

Breast reduction is supported when the record documents symptomatic macromastia, unsuccessful conservative treatment, and the procedure performed.

ALL of the following

Height and weight are documented.
Body surface area (BSA) is documented.
Clinical signs or symptoms attributed to macromastia are documented, including prior therapies and the patient's response to those therapies.
The operative report documents the weight of tissue removed from each breast as measured in the operating room.
The pathology report documents the weight of tissue removed from each breast.

Mastectomy for gynecomastia

Mastectomy for gynecomastia requires documentation of true glandular gynecomastia, appropriate severity and duration, unsuccessful treatment, and exclusion of underlying causes.

ALL of the following

Glandular breast tissue consistent with true gynecomastia is documented on physical examination and/or confirmed by mammography.
Gynecomastia continues despite treatment or resolution of any underlying causes.
The condition meets Grade III or IV criteria under the American Society of Plastic Surgeons classification.
Hormonal causes, including hyperthyroidism, excess estrogen, high prolactin, and low testosterone, are ruled out through appropriate laboratory testing such as TSH, estradiol, prolactin, testosterone, or LH levels.
Use of drugs or substances known to cause gynecomastia is ruled out.

Procedure-specific reconstructive documentation

Selected reconstructive and functional procedures require procedure-specific documentation establishing the condition, treatment history, and medical necessity.

ALL of the following

For rhinoplasty, the record describes the condition necessitating surgery; for chronic obstruction, it identifies the underlying cause, relevant examination or imaging findings when requested, conservative treatment, its duration, and the postoperative surgical or pathology report when applicable.
For septoplasty, the record documents the medical and antibiotic treatments and their duration for recurrent sinusitis caused by a deviated septum, or documents medical management and treatment duration for obstructed nasal breathing caused by septal deformity or deviation that interferes with effective CPAP use. If an asymptomatic deformity is corrected solely to facilitate access during another medically necessary transnasal surgery, the primary procedure is identified.
For dermabrasion, the record clearly documents the injury, surgical procedure, or disease process that caused the defect.
For abdominal lipectomy or panniculectomy, the record includes evaluation and management documentation supporting medical necessity or complications, the operative report, a description of the pannus and underlying skin, chronic intertrigo caused by the panniculus, conservative treatments and outcomes, and evidence of stable weight for a minimum of 6 months.

Cosmetic procedure billing and coverage

Claims must use compliant codes and supporting diagnoses, and procedures generally considered cosmetic may be reviewed or denied as non-covered.

ALL of the following

Report all applicable diagnoses supporting medical necessity in accordance with CMS LCA requirements, including supporting diagnoses when applicable.
Report CPT, HCPCS, and revenue codes only for services actually performed or items actually supplied and document them in the medical record to the highest level of specificity.
Recognize that listed cosmetic procedures may be reviewed or denied as non-covered services.

Billing and reimbursement requirements

Claims and reimbursement remain subject to applicable government, contractual, provider-manual, coding, billing, documentation, authorization, and medical-necessity requirements.

ALL of the following

Applicable CMS and/or MDHHS guidelines and governing contractual or provider-manual requirements are followed.
Required authorization and medical necessity requirements appropriate to the procedure, diagnosis, and frequency are satisfied when applicable.
Services and supplied items are actually performed or supplied, fully documented in the medical record to the highest level of specificity, and reported with compliant CPT, HCPCS, and revenue codes.
Diagnosis coding supports medical necessity in accordance with applicable CMS LCA requirements.
Authorization is not treated as a guarantee of payment and does not supersede coding, billing, reimbursement, documentation, or other policy requirements.

Covered, Excluded, and Required Codes

ICD-10 codes that exclude coverage for any serviceICD-10Not Covered

Z41.1	Encounter for cosmetic surgery
Z41.9	Encounter for procedure for purposes other than remedying health state, unspecified
Z42.8	Encounter for other plastic and reconstructive surgery following medical procedure or healed injury

Reconstructive breast surgery and breast implant proceduresmixedCovered

19316	Mastopexy
19325	Breast augmentation with implant
19328	Removal of intact breast implant
19330	Removal of ruptured breast implant, including implant contents
19340	Insertion of breast implant on the same day as mastectomy
19342	Insertion or replacement of breast implant on a separate day from mastectomy
19350	Nipple or areola reconstruction
19355	Correction of inverted nipples
19357	Tissue expander placement in breast reconstruction, including subsequent expansion
19364	Breast reconstruction with latissimus dorsi flap

1–10 of 11

1/2

Reduction mammaplastyCPTCovered

19318

Breast reduction

Mastectomy for gynecomastiaCPTCovered

19300

Mastectomy for gynecomastia

TattooingCPTCovered

11920	Tattooing or intradermal introduction of insoluble opaque pigments for skin color defects, 6.0 square centimeters or less
11921	Tattooing or intradermal introduction of insoluble opaque pigments for skin color defects, 6.1 to 20.0 square centimeters
11922	Each additional 20.0 square centimeters or part thereof for tattooing

Punch graftCPTCovered

15775	Punch graft for hair transplant, 1 to 15 punch grafts
15776	Punch graft for hair transplant, more than 15 punch grafts

Rhinoplasty and nasal reconstructive surgeryCPTCovered

30400	Primary rhinoplasty involving lateral and alar cartilages and/or elevation of nasal tip
30410	Primary complete external rhinoplasty
30420	Primary rhinoplasty including major septal repair
30430	Secondary rhinoplasty, minor revision
30435	Secondary rhinoplasty, intermediate revision
30450	Secondary rhinoplasty, major revision
30460	Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, tip only
30462	Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including tip, septum, and osteotomies
30520	Septoplasty or submucous resection

DermabrasionCPTCovered

15781

Segmental dermabrasion of the face

Chemical peelCPTCovered

15788	Facial epidermal chemical peel
15789	Facial dermal chemical peel
15792	Nonfacial epidermal chemical peel
15793	Nonfacial dermal chemical peel

Abdominal lipectomy and panniculectomyCPTCovered

15830	Excision of excessive abdominal skin and subcutaneous tissue, infraumbilical panniculectomy
15847	Excision of excessive abdominal skin and subcutaneous tissue, including abdominoplasty components
15877	Suction-assisted lipectomy of trunk

Dermal filler and injection codes subject to medical necessity and benefit limitationsmixedCovered

G0429	Dermal filler injection for facial lipodystrophy syndrome
Q2026	Injection of Radiesse, 0.1 mL
Q2028	Injection of Sculptra, 0.5 mg

Procedures generally considered cosmetic and subject to review or denial as non-coveredCPTNot Covered

11950	Subcutaneous injection of filling material, 1 cc or less
11951	Subcutaneous injection of filling material, 1.1 to 5.0 cc
11952	Subcutaneous injection of filling material, 5.1 to 10.0 cc
11954	Subcutaneous injection of filling material, over 10 cc
15780	Total-face dermabrasion
15782	Regional dermabrasion other than face
15783	Superficial dermabrasion at any site
15828	Rhytidectomy of cheek, chin, and neck
15829	Rhytidectomy with superficial musculoaponeurotic system flap
15832	Excision of excessive skin and subcutaneous tissue of thigh

1–10 of 24

1/3

Dermal filler and injection codesHCPCS

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

Procedures generally considered cosmetic and subject to non-coverage reviewCPTNot Covered

11950	Subcutaneous injection of filling material, 1 cc or less
11951	Subcutaneous injection of filling material, 1.1 to 5.0 cc
11952	Subcutaneous injection of filling material, 5.1 to 10.0 cc
11954	Subcutaneous injection of filling material, over 10.0 cc
15780	Dermabrasion, total face
15782	Dermabrasion, regional, other than face
15783	Dermabrasion, superficial, any site
15828	Rhytidectomy of cheek, chin, and neck
15829	Rhytidectomy with superficial musculoaponeurotic system flap
15832	Excision of excessive skin and subcutaneous tissue of thigh

1–10 of 24

1/3

Required claim code systemsmixed

CPT	Current Procedural Terminology codes required for applicable claim submissions
HCPCS	HCPCS codes required for applicable claim submissions
Revenue	Revenue codes required for applicable claim submissions

Breast Reduction Conservative Treatment

Required durationAt least 6 months of conservative treatment

SymptomsBack, neck, or shoulder pain related to macromastia must persist

Conservative measuresTreatment may include analgesics, supportive garments, and physical therapy

Gynecomastia Medical Treatment

Authorization, Billing, and Documentation Actions

Prior Authorization

Medicare PSOD Required When Criteria Are Not Met

For Medicare indications that do not meet the criteria of an applicable National Coverage Determination (NCD), Local Coverage Determination (LCD), or specific medical policy, complete a Pre-Service Organization Determination (PSOD) before providing the service. Consult the Provider Manual for PSOD requirements.

Prior Authorization

Check Prior Authorization Requirements

Verify whether prior authorization is required before furnishing services. Authorization requirements may depend on the procedure, diagnosis, frequency, setting, benefit plan, or Provider Manual requirements.

Documentation Required

Policy Definitions

Cosmetic Surgery

TermCosmetic surgery

PurposeServices performed to improve or enhance appearance

Functional effectThe services do not affect function

Reconstructive Surgery

TermReconstructive surgery

PurposeServices performed to restore or improve function

Conditions addressedAbnormalities or deformities caused by birth conditions, injury, or disease

Policy Summary

PayerPriority Health Medicare

PolicyCosmetic and Reconstructive Surgery

Policy CodePolicy N/A

Change TypeModified

Effective DateMay 28, 2026

Next Review DateAugust 2026

SourceLink

On This Page

Back, neck, or shoulder pain related to macromastia persists despite at least 6 months of conservative treatment, including analgesics, supportive measures such as garments, and physical therapy.

Gynecomastia continues after at least 6 months of unsuccessful medical treatment.

The condition has been present for at least 1 year.

For rhytidectomy, the record includes the evaluation and management note supporting the decision for surgery, the surgical note, and records showing functional impairment when applicable.

Required durationAt least 6 months of unsuccessful medical treatment

PersistenceGynecomastia must continue despite treatment or resolution of underlying causes

DocumentationThe medical record must show the treatment was unsuccessful

Gynecomastia Duration

Required durationThe condition must have been present for at least 1 year

ConditionDocumented gynecomastia must continue over the required period

Classification basisThe one-year duration requirement is specified per the American Society of Plastic Surgeons

Gynecomastia Severity

Required classificationAmerican Society of Plastic Surgeons classification

Minimum severityGrade III

Alternative qualifying severityGrade IV

Stable Weight for Panniculectomy

Required durationA minimum of 6 months

Weight requirementThe individual must maintain a stable weight

Procedure contextThe requirement applies to abdominal lipectomy or panniculectomy documentation

Support Medical Necessity

Submit documentation and diagnosis coding that establish reconstructive intent, functional impairment, and medical necessity. Reconstructive procedures may be reimbursed when medically necessary to restore function or correct an abnormality; procedures performed only to improve appearance or without functional impairment are not payable.

Billing Rule

Apply Cosmetic-Service Billing Rules

Distinguish cosmetic services from reimbursable reconstructive services when selecting and submitting codes. Report appropriate diagnosis codes and all applicable supporting diagnoses; cosmetic-purpose coding may exclude coverage.

Denial Risk

Denial Risk for Unsupported Claims

Claims may be denied when the diagnosis indicates a cosmetic purpose, documentation does not support reconstructive intent or functional impairment, diagnosis coding does not establish medical necessity, or required diagnosis information is missing.

Examples of cosmetic-purpose coding include Z41.1, Encounter for cosmetic surgery; Z41.9, Encounter for procedure for purposes other than remedying health state, unspecified; and Z42.8, Encounter for other plastic and reconstructive surgery following medical procedure or healed injury.

Prior Authorization

Use the Appropriate Place of Service

Provide services in a setting appropriate to the patient's medical needs and condition. Obtain authorization when required and consult the Provider Manual for place-of-service and authorization guidance.

Documentation Required

Submit Complete Documentation

Maintain and submit complete, thorough, and specific records substantiating the procedure performed and medical necessity. Consult any applicable defined guidelines for additional documentation requirements.

Documentation of services rendered or items supplied must support the claim to the highest level of specificity.

Billing Rule

Apply Modifiers Only When Supported

Follow standard billing and coding guidelines, including CMS National Correct Coding Initiative (NCCI) guidance. Apply modifiers only when applicable and supported by the medical record.

Prior Authorization

Authorization Is Not a Payment Guarantee

An authorization on file does not guarantee payment. Payment remains subject to medical necessity, applicable procedure, diagnosis, frequency, benefit, policy, contractual, and proper billing and coding requirements.

Denial Risk

Cosmetic Procedures May Be Denied

Treat the listed cosmetic procedures as subject to review and potential denial as non-covered services when performed for cosmetic purposes. Coverage depends on the applicable medical-necessity and benefit requirements.

Examples include CPT 11950–11954, 15780, 15782–15783, 15828–15829, 15832–15839, 15876, 15878–15879, 17340, 17360, 17380, and 69300.

Prior Authorization

Authorization Does Not Override Claim Requirements

Require authorization when applicable, but do not treat authorization as overriding medical-necessity, coding, billing, reimbursement, or frequency requirements. Authorization for an item or service does not supersede these requirements.

Billing Rule

Submit Supported and Documented Codes

Submit only compliant CPT, HCPCS, and revenue codes for services performed or items supplied. Codes must be fully documented in the medical record and reported to the highest level of specificity.

Documentation Required

Support Medical Necessity With Diagnosis Coding

Ensure diagnosis coding supports medical necessity under applicable CMS Local Coverage Article (LCA) requirements and report all applicable diagnoses. Claims with insufficient diagnosis information may be denied.

Denial Risk

Avoid Denial and Payment Recovery

Follow government program regulations, policy requirements, contractual requirements, and proper billing and submission guidelines. Noncompliance may result in claim rejection or denial and recovery or recoupment of payments.

Failure to document services rendered or items supplied may result in denial.
An authorization on file does not prevent denial or payment recovery when coding, billing, reimbursement, or policy requirements are not met.

Note

Prepare for Payment-Integrity Review

Be prepared for pre-claim or post-claim payment-integrity review of billing and coding accuracy, including review for fraud, waste, and abuse. Maintain records that substantiate every billed service, item, code, and diagnosis.

Chronic Intertrigo

TermChronic intertrigo

DefinitionInflammation of opposing skin surfaces

Examples of associated effectsIrritation, infection, or chafing

BSA

AbbreviationBSA

Full termBody surface area

Documentation useBody surface area must be included in the medical record for breast reduction