Cosmetic and Reconstructive Procedures
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Medicare medical policy governing determination of coverage for cosmetic versus reconstructive plastic and reconstructive surgery procedures for Providence Health Plan Medicare members; guides prior authorization and claims decision-making based on Medicare rules, LCDs/NCDs, member EOCs, and clinical necessity.
Interim update; revised criteria for penile implants for impotence.
Removed dermal filler injections for facial lipodystrophy syndrome.
Replaced L37020 with L35163 and updated companion LCA due to Noridian JF consolidation with JE LCD policies.
Replaced L33979 with L34233 and updated companion LCA due to Noridian JF.
All unlisted codes are reviewed for medical necessity, correct coding, and pricing at the claim level; prior authorization is recommended for unlisted codes for potentially covered services to avoid post-service denial.
Coverage Criteria
General Medicare medical necessity criteria
Coverage depends on whether procedure is cosmetic or reconstructive and on member contract/EOC and applicable Medicare references.
Use applicable LCDs/LCA/NCD and cross-referenced Company policies for procedure-specific criteria and prior authorization guidance.
Benign Skin Lesion Removal (reconstructive criteria)
Benign Skin Lesion Removal — reconstructive coverage condition
Refer to the cited LCD/LCA for the specific diagnostic and clinical criteria required for coverage; these codes may otherwise be considered cosmetic and non-covered.
Dermabrasion (CPT 15780-15783)
Dermabrasion — reconstructive coverage condition
See the Plastic Surgery LCA (Group 1 ICD-10 Codes) for the complete list of acceptable diagnosis codes required for coverage.
Cosmetic surgery and services incurred in connection with cosmetic surgery are excluded from Medicare coverage. Per the Medicare Benefit Policy Manual, Chapter 16 §120, cosmetic surgery is defined as any surgical procedure directed at improving appearance and is not covered except when required for the prompt repair of accidental injury or to improve the functioning of a malformed body member. Determinations of cosmetic versus reconstructive status must follow Medicare guidance and the member's Evidence of Coverage; if a direct member contract exclusion applies, the service should be denied as not a covered benefit.
Ear and body piercing are considered cosmetic procedures and are not covered benefits under this policy. Providers should not expect Medicare or plan reimbursement for ear or body piercing services.
CPT code 69090 (ear piercing) is a statutorily excluded, non‑covered service. The NPFSRVF assigns CPT 69090 Status Indicator 'N' (Non‑covered Services), and the procedure is excluded under the Social Security Act, Section 1862(a)(1)(A).
If an unlisted code is submitted for a service that is non‑covered under this policy, the claim will be denied as not covered. Providers should not expect unlisted procedure submissions to convert a non‑covered service into a covered one.
When an unlisted code is used to describe a service addressed in this policy, duplicate or alternate unlisted codes will be reviewed and, if the service is determined to be non‑covered, denied as not covered. To avoid post‑service denials for potentially covered services, prior authorization is recommended when using unlisted codes.
Removal of benign skin lesions (for example, skin tags, moles, warts) that do not pose a threat to health or function is considered cosmetic and is not covered by Medicare. Such removals may be considered reconstructive and medically necessary only when the criteria in the applicable Local Coverage Determination/Article are met.
Some procedure codes are considered cosmetic and non‑covered for all indications, while other codes may be covered only when billed with specific diagnoses (for example, certain procedures billed with diagnosis codes F64.0–F64.9). Providers must confirm whether a code is non‑covered for all indications or only covered for specified diagnoses by reviewing this policy, applicable LCAs, and member EOC language.
The issuance of a CPT or HCPCS code or the presence of a payment amount in the Medicare Physician Fee Schedule does not imply that the procedure is medically reasonable, necessary, or a covered benefit. Inclusion of a code in this policy or in Medicare fee schedules does not guarantee coverage.
Coding and Code Handling
| CPT 10040 | Extraction (previously acne surgery); used for marsupialization and opening/removal of cysts, pustules, comedones, and milia |
| CPT 11200 | Skin tag removal |
| CPT 11201 | Skin tag removal (additional code referenced) |
| CPT 69090 | Ear piercing (non-covered Medicare Status 'N' code) |
| CPT 54400 | Penile prosthesis implantation (example codes listed) |
| CPT 54401 | Penile prosthesis implantation |
| CPT 54405 | Penile prosthesis implantation |
| CPT 54410 | Penile prosthesis implantation |
| HCPCS C1813 | Penile prosthesis device (example HCPCS listed) |
| HCPCS C2622 | Penile prosthesis device (example HCPCS listed) |
| 15780 | Dermabrasion; total face |
| 15781 | Dermabrasion; segmental, face |
| 15782 | Dermabrasion; regional, other than face |
| 15783 | Dermabrasion; superficial, any site |
| 17999 | Unlisted procedure, skin, mucous membrane and subcutaneous tissue |
| 40799 | Unlisted procedure, lips / external ear (used as example) |
| 69399 | Unlisted procedure, eyelids |
| 69090 | Ear piercing (status: non-covered per NPFSRVF) |
| 17106 | Destruction of vascular proliferative lesions |
| 17107 | Destruction of vascular proliferative lesions |
| Group 1 ICD-10 Codes | Diagnosis codes listed in the Plastic Surgery LCA required when billing dermabrasion (CPT 15780-15783) for reconstructive necessity |
| L37020 | legacy HCPCS/LCD identifier replaced |
| L35163 | replacement HCPCS/LCD identifier |
| L33979 | legacy HCPCS/LCD identifier replaced |
| L34233 | replacement HCPCS/LCD identifier |
| unlisted codes | All unlisted CPT/HCPCS codes are subject to claim-level review and may require prior authorization if for potentially covered services. |
Provider Actions and Billing Guidance
Determine cosmetic vs reconstructive before authorization
Before requesting authorization, determine whether the planned service is cosmetic or reconstructive and check the member's Evidence of Coverage (EOC), since contract language takes precedence and will govern coverage decisions.
Prior authorization may be required
Some procedure codes may require prior authorization for all indications; verify prior auth requirements per the Company non-covered and prior authorization lists before scheduling.
- Some codes are cosmetic and non‑covered for all indications; others require prior authorization for all indications.
- Refer to Company non‑covered and prior authorization lists for details.
Prior authorization recommended
For unlisted codes or procedures that may be potentially covered, obtain prior authorization to avoid post‑service denial — prior authorization is recommended when submitting unlisted codes for potentially covered services.
Documentation for medical necessity
Document clinical evidence of illness, injury, or functional impairment and include relevant clinical notes and physician rationale; plan medical director involvement may be required for medical necessity determinations.
- Include documentation that the service treats an illness, injury, or functional impairment (i.e., reconstructive need).
- Provide clinical notes, diagnoses, and any supporting evidence used for the medical necessity decision.
Use LCAs and expect claim-level review
Follow associated Local Coverage Articles (LCAs) for coding and billing guidance and expect that unlisted codes will be reviewed at the claim level for medical necessity, correct coding, and pricing.
- See relevant LCA (e.g., Benign Skin Lesion Removal, Plastic Surgery LCA) for acceptable diagnosis-code mappings.
- Anticipate claim‑level review and potential requests for additional documentation when unlisted codes are submitted.
Unlisted code review
All unlisted CPT/HCPCS codes are subject to claim‑level review for medical necessity, correct coding, and pricing; be prepared to justify code selection and provide supporting documentation on request.
Cosmetic procedures excluded — provider action
Do not submit procedures that are cosmetic and non‑covered under Medicare (per CMS Benefit Policy Manual Chapter 16 §120) without confirming the member's EOC; such services should be denied as not a covered benefit.
- If a direct member contract exclusion applies, deny the service as not a covered benefit.
- Removal of benign skin lesions that do not threaten health or function is considered cosmetic and not covered unless LCD criteria are met.
Unlisted code denial risk
Unlisted codes submitted for services that are non‑covered under this policy will be denied as not covered; providers risk post‑payment denial if choosing unlisted codes without prior authorization for potentially covered services.
- If an unlisted code is submitted for non‑covered services addressed in this policy it will be denied as not covered.
- Prior authorization is recommended for unlisted codes used for potentially covered services to avoid post‑service denial.
Denial for unlisted codes for non-covered services
If an unlisted code is used to report a service that is not covered under this policy, the claim will be denied as not covered — do not rely on an unlisted code to obtain payment for non‑covered cosmetic services.
Background
Reconstructive surgery is performed on abnormal body structures caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease and is generally intended to improve function or to approximate a normal appearance. The primary purpose of reconstructive procedures is restoration of function or correction of an anatomic deformity; cosmetic improvement alone does not meet Medicare's definition of medical necessity.
Definitions
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