Currentselect_healthPolicy CCP.1184

Plastic reconstructive surgery

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Describes coverage guidance for plastic (reconstructive) surgical procedures that correct functional impairments and distinguishes reconstructive (medically necessary) from cosmetic (not medically necessary) procedures; applies to Select Health of South Carolina coverage determinations and providers requesting coverage.

Policy Summary

PayerSelect Health of South Carolina

PolicyPlastic reconstructive surgery

Policy CodePolicy CCP.1184

Change TypeNo material clinical or coverage changes

Effective DateOct 1, 2025

Last ReviewOct 20, 2025

Next Review DateFeb 1, 2027

Key ActionObtain prior review by a Select Health Medical Director for all non‑Medicare member plastic surgery requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2core criteria required for medical necessity

prior review requirednon-Medicare plastic surgery requests

policy updatedmost recent review

9/9/2025literature search through

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Currentselect_healthPolicy CCP.1184

Plastic reconstructive surgery

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Sign up for select_health Policy CCP.1184 alerts

Get alerted when Policy CCP.1184 changes without checking for updates manually.

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Policy Summary

PayerSelect Health of South Carolina

PolicyPlastic reconstructive surgery

Policy CodePolicy CCP.1184

Change TypeNo material clinical or coverage changes

Effective DateOct 1, 2025

Last ReviewOct 20, 2025

Next Review DateFeb 1, 2027

Key ActionObtain prior review by a Select Health Medical Director for all non‑Medicare member plastic surgery requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2core criteria required for medical necessity

prior review requirednon-Medicare plastic surgery requests

policy updatedmost recent review

9/9/2025literature search through

Coverage Criteria

Reconstructive (Medically Necessary) Surgery

Covered when ALL of the following are met

Clinical proof of need: The need for the surgical procedure is clinically proven.

Support with documentation showing impairment and medical necessity.

Functional impairment goal: The goal of surgery is to correct a functional impairment of a body area caused by a congenital defect, trauma, burns, infection, tumors, or disease.

Functional impairment defined as a direct and measurable reduction in physical performance of the target organ or body part.

Surgery performed solely to improve body appearance in the absence of a functional impairment is considered cosmetic and, therefore, not medically necessary.

Procedures intended only for aesthetic improvement when no functional impairment exists are not medically necessary (cosmetic) and are not covered under this policy.

Provider Actions and Requirements

Prior Authorization

Prior review required for non‑Medicare members

All requests for coverage of plastic surgery for a non‑Medicare member must receive prior review by a Select Health Medical Director on a case‑by‑case basis, except when the procedure is addressed in another clinical policy or is required by state or federal authorities.

Step Therapy

Consider alternative covered services prior to surgery

Before surgical intervention, consider and document clinically appropriate alternative covered services such as prescription drug therapy or behavioral health services when applicable.

Prescription drug therapy may be appropriate for certain conditions.
Behavioral health services.

Documentation Required

Definitions

inv-09: Functional impairment

DefinitionA direct and measurable reduction in physical performance of an organ or body part that is the target of surgery to improve function.

Measurement focusEmphasizes objective, functional loss (physical performance) of the specific body area to be treated.

Clinical relevanceSurgery is indicated when correcting the impairment will improve function caused by congenital defect, trauma, burns, infection, tumors, or disease.

inv-10: Cosmetic surgery

DefinitionElective surgical procedures intended to reshape structures of the body to improve aesthetic appeal, symmetry, and proportion when the treated areas function properly.

PurposeFocused entirely on improving appearance rather than restoring or improving physiological function.

Background

Plastic (reconstructive) surgery is focused on correcting functional impairments of the face and body caused by congenital defects, trauma, burns, infection, tumors, or disease. When the primary goal of a surgical procedure is to restore or improve function because of a demonstrable impairment, the procedure may be considered reconstructive and medically necessary. Conversely, elective procedures whose sole purpose is to improve appearance—where function is normal—are classified as cosmetic and not medically necessary. For non‑Medicare members, requests for coverage of plastic surgery require prior review by a Medical Director on a case‑by‑case basis unless covered by another clinical policy or mandated by law.