Reconstructive and Cosmetic Health Services
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Defines medical necessity criteria, examples of reconstructive services that are covered, and examples of cosmetic services that are not medically necessary for UCare members; applies to providers submitting coverage requests and prior authorizations in Minnesota and other UCare plans as described.
No material clinical or coverage changes in this revision.
Reconstructive and Cosmetic Services — Coverage Criteria
Reconstructive services — medical necessity
Services are RECONSTRUCTIVE and MEDICALLY NECESSARY when ALL of the following are met:
Reconstructive necessity
- 1) Service is intended primarily to restore function and/or correct a physical abnormality resulting in a functional defect from accidental injury, trauma, disease, previous surgery, or congenital malformations when likely to cause future physiologic impairment.
- 2) The functional defect results in either significant disability that interferes with activities of daily living or exacerbation of a medical condition.
- 3) Medical documents submitted to UCare substantiate how the proposed surgery will improve the function of the body part (examples: operative reports, photographs, specialty consultations, diagnostic imaging).
Provide relevant supporting documentation with the authorization request or medical record submission.
- 4) The primary purpose for the procedure is NOT cosmetic; improvement in appearance alone does not meet medical necessity unless the functional criteria are satisfied.
- 5) The procedure is NOT performed solely to relieve psychological symptoms or socially avoidant behavior.
Cosmetic services are NOT MEDICALLY NECESSARY. Examples include, but are not limited to, abdominoplasty or panniculectomy performed primarily to improve appearance, adipose tissue replacement by insertion or injection of prosthetic material, breast augmentation (augmentation mammoplasty) of small but otherwise normal breasts, breast implant removal or revision for non‑medical reasons, inverted nipple correction, breast lift (mastopexy) for sagging, diastasis recti repair, ear piercing and earlobe repair to close a stretched pierce hole, and excision of excess skin from thigh, leg, hip, buttock, arm, forearm, hand, submental area, neck, or other areas.
Procedures listed under 'COSMETIC SERVICES' are explicitly identified as NOT MEDICALLY NECESSARY. Representative procedures include facial contouring (e.g., chin implant or cheek enhancement) and facial rejuvenation (rhytidectomy/face lift, eyelid lift, neck lift, brow lift, glabellar line correction, injectable fillers), tattooing for color correction, hair removal or replacement, lipectomy/liposuction, medical skin treatments for photo‑aged skin or acne scarring (e.g., dermabrasion, chemical exfoliation, laser resurfacing), otoplasty for appearance only, rhinoplasty performed for cosmetic purposes, sclerosing of spider veins, septoplasty solely for appearance, skin lesion removal for cosmetic reasons, tattoo removal for decorative tattoos, treatment of non port‑wine stain hemangiomas primarily for appearance, vaccination scar revision, vaginal rejuvenation procedures (including labia reduction), and vermilionectomy.
Provider Requirements and Prior Authorization
Obtain prior authorization for listed reconstructive services
A prior authorization must be obtained for reconstructive services listed on UCare’s provider authorization webpage; for other reconstructive procedures prior authorization is not required but UCare may review medical records after the procedure. Providers may submit clinical information before the procedure using the UCare prior authorization form or the Medicare pre-determination request forms available on the UCare authorization page.
- Submit requests via UCare Prior Authorization or Medicare Pre-Determination Request Forms available at https://www.ucare.org/providers/authorization
Document trial of 5‑FU or imiquimod before dermabrasion
For dermabrasion of multiple superficial lesions, the policy requires a trial of topical 5‑fluorouracil (5‑FU) or imiquimod unless those therapies are contraindicated or impractical; absence of such trial should be documented. This requirement supports medical necessity when conventional methods are impractical and 5‑FU/imiquimod have failed or cannot be used.
- Document trial and outcome of 5‑fluorouracil (Efudex) or imiquimod (Aldara), or document contraindication/impracticality
- Show that conventional removals (cryotherapy, curettage, excision) were impractical due to number/distribution of lesions
Provide documentation showing how surgery will improve function
Submit medical documentation that substantiates how the proposed surgery will improve function of the affected body part. Acceptable supporting documents include operative reports, clinical photographs, specialty consultation notes, and diagnostic imaging.
- Operative reports detailing the functional defect and planned correction
- Photographs demonstrating deformity or functional impairment
- Specialty consultation notes describing functional limitation
- Diagnostic imaging that documents the underlying abnormality
Risk of denial if authorization not obtained for listed services
Failure to obtain prior authorization for reconstructive services that are listed on UCare’s reconstructive services authorization page may result in post-service review and potential denial or billing issues. Providers should obtain authorization before performing listed procedures to avoid claim denials.
- UCare may perform post-procedure medical record review for procedures without prior authorization
- Lack of prior authorization for listed services may lead to denial or billing problems
Background
Reconstructive services are intended to restore function or to correct deformities resulting from disease, trauma, injury, prior surgery, or congenital anomalies. To be considered reconstructive and medically necessary, services must be proven effective and likely to significantly improve or restore functional ability rather than being performed primarily to improve appearance.
Key Definitions
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