Cosmetic and Reconstructive Procedures
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Defines medical necessity criteria, exclusions, and coding guidance for cosmetic and reconstructive surgical procedures for QualChoice members; affects providers submitting claims and requests for prior authorization.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Reconstructive medical necessity
Reconstructive procedures are considered medically necessary when meeting ALL of the following:
Intent of the procedure (ONE of the following)
- Reconstructive indications: 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)
- Skin tag removal: Removal of a skin tag when located in an area that affects eyesight or in an area of friction with documentation of repeated irritation and bleeding (refer to Benefit Plan Contract for coverage restrictions)
- Scar or keloid revision: Scar/keloid revision or removal when accompanied by pain unresponsive to conservative therapy and is recurrently infected, unstable, friable, or associated with functional impairment
- Breast reconstruction when appearance is sole benefit: Certain reconstructive procedures may be covered even if improving appearance is the only benefit (for example, post-mastectomy breast reconstruction including nipple reconstruction, tattooing, and surgery on the contralateral breast to restore symmetry)
Includes post-mastectomy and reconstruction for loss of breast tissue due to congenital or non-congenital disease or for prophylaxis against future disease; prior conservative therapy not required for these breast indications.
- HIV-associated facial wasting treatments: Use of FDA‑approved facial dermal injections (poly‑L‑lactic acid, calcium hydroxylapatite) or autologous fat transfer for HIV‑associated wasting when BOTH diagnoses are present: diagnosis of HIV or AIDS AND diagnosis of facial lipodystrophy syndrome (LDS)
Cosmetic not medically necessary
Cosmetic procedures considered not medically necessary
List is illustrative, not exhaustive.
Cosmetic surgery and procedures performed primarily to improve a patient’s normal appearance or self‑esteem are considered not medically necessary and are generally not covered. The policy explicitly lists examples of such cosmetic exclusions to illustrate services typically considered noncovered when performed for appearance alone.
Coverage determinations and benefit administration for any procedure described in this policy are subject to the terms, conditions, exclusions and limitations of the member’s coverage documents (for example, evidence of coverage, certificate of coverage, policy or contract). State and federal requirements and applicable Health Plan administrative policies and procedures also apply and take precedence where required by law.
The policy specifically identifies multiple procedures that are considered cosmetic and not medically necessary when performed to improve appearance or self‑esteem. Examples include: injectable filler; breast augmentation; body contouring and body lift; abdominoplasty; dermabrasion and skin resurfacing/rejuvenation; liposuction (except for lipoma as directed by clinical decision support); excision of excessive skin, including post‑weight‑loss skin removal when solely cosmetic; revision/removal/replacement of implants placed for cosmetic reasons; hair transplantation (unless to correct permanent hair loss from disease/injury); electrolysis/laser hair removal; tattooing (except post‑mastectomy breast reconstruction); mastopexy when performed for cosmetic reasons; correction of inverted nipples and repair of diastasis recti, among others listed in the policy.
Some procedures described in the policy may not include an explicit statement labeling them as not medically necessary. In those cases, the absence of an explicit exclusion does not imply automatic coverage. Coverage for such procedures will default to a clinical review against the plan’s medical necessity criteria and the member’s coverage documents; prior authorization and supporting documentation (including medical records and photographs, when applicable) may be required to determine whether the service meets reconstructive medical‑necessity criteria or is excluded as cosmetic.
CPT and HCPCS Codes
| 11200 | Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions. |
| 11201 | Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof (List separately in addition to code for primary procedure). |
| 11400 | Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter 0.5 cm or less. |
| 11401 | Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter 0.6 to 1.0 cm. |
| 11402 | Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter 1.1 to 2.0 cm. |
| 11403 | Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter 2.1 to 3.0 cm. |
| 11404 | Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter 3.1 to 4.0 cm. |
| 11406 | Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter over 4.0 cm. |
| 11420 | Excision, benign lesion including margins, except skin tag, scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less. |
| 11421 | Excision, benign lesion including margins, except skin tag, scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm. |
| 21261 | Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and extracranial approach. |
| 21263 | Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement. |
| 21267 | Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach. |
| 21268 | Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and extracranial approach. |
| 21270 | Malar augmentation, prosthetic material. |
| 21275 | Secondary revision of orbitocraniofacial reconstruction. |
| 21280 | Medial canthopexy (separate procedure). |
| 21282 | Lateral canthopexy. |
| 21295 | Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approach. |
| 21296 | Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach. |
Prior Authorization, Documentation, and Provider Responsibilities
Prior authorization / adjudication for reconstructive breast procedures
Reconstructive breast procedures that support the medical necessity criteria (including but not limited to CPT codes 19301, 19303, 19340, 19342, 19350, 19357, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396, 19499) may require adjudication or prior authorization per the payer's processes; submit requests following the Health Plan's authorization workflow.
- Include the specific CPT code(s) listed on the claim or prior authorization request.
- Support requests with documentation that meets the reconstructive medical necessity criteria in the policy.
Prior authorization expectation for certain procedures and injectable treatments
Certain enumerated procedures and HCPCS-coded injectable treatments (for example: 21261, 21263, 21267, 21268, 21270, 21275, 21280, 21282, 21295, 21296, 61550–61559, G0429, Q2026, Q2028) are subject to Health Plan coverage review and applicable authorization processes under plan rules.
- Follow the Health Plan's prior authorization process for listed procedures and HCPCS-coded injectable treatments.
- Authorization requirements are determined per the member's plan and Health Plan administrative rules.
Confirm procedure intent and provide clinical justification
When requesting coverage or submitting claims, ensure the procedure purpose aligns with the policy's reconstructive criteria and include all required clinical information for review.
- Indicate the reconstructive intent (e.g., improve function, post-mastectomy reconstruction) on requests.
- Attach relevant clinical notes describing failure of conservative therapy when applicable.
Follow Health Plan authorization procedures and include codes and rationale
Submit prior authorization or coverage review requests according to Health Plan processes and include the specific CPT/HCPCS codes and clinical rationale to facilitate adjudication.
- Use the member's coverage documents and the Health Plan's administrative procedures to determine submission route and timelines.
- Incomplete requests may delay review or result in denial.
Provide medical records and photographs when applicable
Medical records with photographs are required, as applicable, to support reconstructive procedure requests and demonstrate the clinical condition necessitating treatment.
- Include preoperative photographs and relevant clinical imaging where applicable.
- Ensure documentation shows location, extent, and functional impact when claiming medical necessity.
Adhere to Health Plan policy and member coverage; state Medicaid provisions prevail when applicable
Providers must follow the Health Plan's clinical policy and the member's coverage documents when submitting requests; for Medicaid members, state Medicaid coverage provisions take precedence where they conflict with this clinical policy.
- Check the member's evidence of coverage or contract for specific benefit limitations and exclusions.
- For Medicaid members, consult the state Medicaid manual for applicable coverage rules.
Denial risk for procedures that are cosmetic only
Procedures performed solely to improve normal appearance (cosmetic procedures listed in the policy, e.g., injectable filler, breast augmentation, abdominoplasty, body contouring, dermabrasion, tattooing except post-mastectomy) are considered not medically necessary and may be denied.
- Do not submit requests as reconstructive if the only benefit is cosmetic appearance; such claims are subject to denial.
- If a procedure is both cosmetic and reconstructive, provide clear documentation demonstrating medical necessity per policy criteria.
Coverage decisions depend on the member's contract and applicable laws
Coverage decisions and administration of benefits are subject to all terms, conditions, exclusions and limitations of the member's coverage documents and applicable state and federal requirements; verify member benefits before submission.
- Pre-authorization or payment is not guaranteed by policy alone—final determination aligns with the member's contract and plan-specific rules.
- Discrepancies between this clinical policy and legal/regulatory requirements are governed by law.
Background and Scope
Reconstructive surgery is intended to treat abnormal body structures resulting from congenital defects, trauma, prior surgery, infection, tumors or disease, typically to improve function and, where appropriate, to restore appearance. Procedures meet reconstructive medical necessity when the intent and supporting conditions in the policy are satisfied (for example, improvement of function of an abnormal body part after conservative therapy has failed, or reconstruction after mastectomy). Medical records, including photographs when applicable, are required to support reconstructive indications.
Key Definitions
Policy Revision History and References
Policy AR.CP.MP.31 (Cosmetic and Reconstructive Procedures) was last revised; effective and last review date recorded as 2025-09-12.
Reference list and external guidance sources (UpToDate, ASPS resources, CMS L33428, package inserts) were accessed or cited on June 21, 2024 for inclusion in the policy references.
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