CurrentUnitedHealthcarePolicy MMP022.14

Cosmetic and Reconstructive Procedures

Defines Medicare Advantage coverage distinctions between cosmetic and reconstructive surgical procedures, provides condition-specific guidance where no LCD/NCD exists, references applicable LCDs/LCAs and related policies, and lists CPT/HCPCS codes that may be cosmetic or reconstructive or are considered cosmetic (not covered). Applies to Medicare Advantage claims and notes state/local LCD/LCA applicability.

Policy Summary

PayerUnitedHealthcare

PolicyCosmetic and Reconstructive Procedures

Policy CodePolicy MMP022.14

Change TypeMultiple additions, removals, and revisions

Effective DateOct 1, 2025

Next Review Date

Key ActionProvide preoperative photographs and clinical documentation (symptom history, prior therapy, weight stability, and applicable LCD/LCA references) to support medical necessity and coverage determinations.

POLICY UPDATE CHANGES

Removed reference link to the UnitedHealthcare Commercial Medical Policy titled 'Cosmetic and Reconstructive Procedures Coverage Rationale'.

Removed content/language addressing autologous soft tissue and fat grafting (refer to Medicare Coverage Database for applicable guidelines).

Revised coverage guidelines for states/territories with no LCDs/LCAs to allow preoperative photographs to support justification and updated list of indications not reasonable and necessary.

Added instruction to refer to the CMS definition of cosmetic and reconstructive surgery for coverage guidelines for states/territories with no LCDs/LCAs.

Added language indicating multiple listed procedures (e.g., electrolysis, injection deoxycholic acid, otoplasty, rhytidectomy, suction assisted lipectomy of head/neck) are considered cosmetic and therefore not reasonable and necessary.

Added instruction to refer to InterQual CP: Procedures, Tissue Transfer (Flap) for coverage guidelines for various flap and tissue transfer procedures.

Removed language that reconstructive surgeries of head and neck are automatically reasonable and necessary for trauma, congenital anomalies, or tumors.

Added instruction to refer to InterQual CP: Procedures, Tissue Transfer (Flap) for coverage guidelines for myocutaneous flaps.

Removed reference link to the UnitedHealthcare Commercial Medical Policy titled 'Cosmetic and Reconstructive Procedures'.

Added language indicating otoplasty is considered cosmetic and therefore not reasonable and necessary.

Added language indicating rhytidectomy is considered cosmetic and therefore not reasonable and necessary.

Added language indicating subcutaneous injection of filling material is considered cosmetic and therefore not reasonable and necessary.

Added language indicating suction assisted lipectomy of head and neck is considered cosmetic and therefore not reasonable and necessary.

Added language indicating toe polydactyly reconstruction may be cosmetic; review required to determine if cosmetic or reconstructive.

Added language indicating unlisted craniofacial and maxillofacial procedure may be cosmetic; review required to determine if cosmetic or reconstructive.

Removed CPT codes 11920, 11921, 11922, 15769, 15771, 15772, 15773, and 15774 from the Applicable Codes list.

Removed definition of 'Panniculectomy'.

Added instruction to refer to the CMS definition of cosmetic and reconstructive surgery for coverage guidelines for states/territories with no LCDs/LCAs.

1Policy sections referencing LCD/LCA requirement

20+CPT/HCPCS codes listed (approx.)

1Not Covered Cosmetic Codes group

31.5%Pooled complication rate (postbariatric BCS)

5,620Patients in BODY-Q longitudinal BCS study

Coverage Summary & Scope

This UnitedHealthcare Medicare Advantage policy clarifies the distinction between reconstructive and cosmetic surgery consistent with Medicare law (Section 1862(a)(1)(A) of the Social Security Act) and the CMS Medicare Benefit Policy Manual. It applies primarily to Medicare Advantage claims and notes that where contractor-specific Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs) exist, compliance with those LCDs/LCAs is required.

When no applicable NCD/LCD/LCA exists for a given procedure, the policy provides procedure-specific guidance and UnitedHealthcare internal criteria informed by clinical evidence and professional guidance; for states/territories with no LCDs/LCAs the policy instructs providers to use the CMS definition of cosmetic versus reconstructive surgery and allows supporting documentation such as preoperative photographs where indicated.

The policy lists numerous referenced LCDs/LCAs and maps them to Medicare Administrative Contractors and states/territories, and it directs providers to follow contractor-specific coverage and billing rules for jurisdictions where those LCDs/LCAs apply.

Policy thresholds & quick facts

Symptom duration>= 3 months (symptoms refractory to usual standard medical therapy)

Weight stability (post-significant weight loss)>= 6 months

Minimum interval after bariatric surgery>= 18 months AND weight stable for most recent 6 months

BMI risk threshold for increased complications after body contouring>= 30 kg/m2

Pannus grade exampleGrade 1 = mons pubis ... Grade 5 = to or past knees

Medical-Necessity Criteria

General Coverage Criteria for Cosmetic vs Reconstructive Surgery

Covered when ALL of the following are met:

ALL of the following

Procedure is reconstructive: performed on abnormal structures caused by congenital defects, developmental abnormalities, trauma, tumors, or disease
Based on Social Security Act §1862(a) and Policy overview
Procedure is reasonable and necessary to improve function of a malformed body member or to treat illness/injury per Section 1862(a)(1)(A) of the Social Security Act
Medicare requirement for reconstructive coverage

Abdominal Lipectomy/Panniculectomy (for states/territories with no LCDs/LCAs)

Considered reconstructive when ALL of the following are met:

ALL of the following

Clinical Evidence & Procedural Considerations

Orbital Reconstruction Materials Evidence Summary

Evidence-based considerations for material selection in orbital floor/wall reconstruction:

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Background: The policy is grounded in Medicare/CMS definitions distinguishing reconstructive procedures (performed to restore function for abnormal structures caused by congenital defects, trauma, tumors, or disease) from cosmetic procedures (performed to improve appearance) and cites Section 1862(a) of the Social Security Act and the Medicare Benefit Policy Manual (Chapter 16, §120).

It references multiple LCDs/LCAs (and provides a table of contractor mappings) and instructs that where LCDs/LCAs exist, compliance is required; where no LCD/LCA exists, the policy supplies specific criteria or refers providers to CMS definitions or InterQual for tissue-transfer/flap procedures.

Cross-references: the policy points to related UnitedHealthcare Medicare Advantage policies (e.g., Brow Ptosis and Eyelid Repair, Ear/Nose/Throat Procedures, DME/Prosthetics Grid) and to UnitedHealthcare commercial medical policies (e.g., Breast Reconstruction, Panniculectomy Surgery, Liposuction for Lipedema) for procedure-specific guidance when Medicare guidance is absent or directs referral.

Coding — Procedure & Reference Codes

Procedure Codes That May Be Cosmetic or Reconstructive (reference list)CPT|HCPCS

15830	Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
15847	Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)
14000	Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less
14001	Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm
14020	Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less
14021	Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm
14040	Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less
14041	Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm
14060	Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less
14061	Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm

1–10 of 83

1/9

Procedure Codes That are Considered Cosmetic (Not Covered)CPT|HCPCSNot Covered

11950	Subcutaneous injection of filling material (e.g., collagen); 1 cc or less
11951	Subcutaneous injection of filling material (e.g., collagen); 1.1 to 5.0 cc
11952	Subcutaneous injection of filling material (e.g., collagen); 5.1 to 10.0 cc
11954	Subcutaneous injection of filling material (e.g., collagen); over 10.0 cc
15786	Abrasion; single lesion (e.g., keratosis, scar)
15787	Abrasion; each additional 4 lesions or less (list separately in addition to code for primary procedure)
15819	Cervicoplasty (Deleted 12/31/2024)
15824	Rhytidectomy; forehead
15825	Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)
15826	Rhytidectomy; glabellar frown lines

1–10 of 17

1/2

Referenced LCDs/LCAs and related contractor mappingsmixed

L33428	LCD: Cosmetic and Reconstructive Surgery
A56658	LCA: Billing and Coding: Cosmetic and Reconstructive Surgery
L39051	LCD: Cosmetic and Reconstructive Surgery
A58774	LCA: Billing and Coding: Cosmetic and Reconstructive Surgery
L38914	LCD: Cosmetic and Reconstructive Surgery
A58573	LCA: Billing and Coding: Cosmetic and Reconstructive Surgery
L39506	LCD: Cosmetic and Reconstructive Surgery
A59299	LCA: Billing and Coding: Cosmetic and Reconstructive Surgery
L35090	LCD: Cosmetic and Reconstructive Surgery
A56587	LCA: Billing and Coding: Cosmetic and Reconstructive Surgery

1–10 of 27

1/3

Removed CPT codes (no longer listed in this policy part)CPT

11920	Removed from Applicable Codes list
11921	Removed from Applicable Codes list
11922	Removed from Applicable Codes list
15769	Removed from Applicable Codes list
15771	Removed from Applicable Codes list
15772	Removed from Applicable Codes list
15773	Removed from Applicable Codes list
15774	Removed from Applicable Codes list

Provider Actions & Prior Authorization / Documentation

Prior Authorization

Prior authorization & LCD/LCA compliance

Compliance with applicable Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs) is required where they exist. Prior authorization (PA) is required per UnitedHealthcare Medicare Advantage procedures and may be delegated to an authorized organization; when delegated, the delegated entity must follow the payer's PA rules and documentation requirements. Providers must submit any required PA requests before elective procedures to avoid claim denials.

Prior authorization required for procedures when an applicable LCD/LCA mandates PA
Delegation allowed — delegated organizations must comply with PA rules and documentation submission

Documentation Required

Panniculectomy documentation requirements

Panniculectomy documentation must include clear evidence to support medical necessity. Required documentation includes: preoperative photographic documentation showing the pannus, a documented symptom history of at least 3 months refractory to standard medical therapy, objective evidence of weight stability when applicable, and documentation of failure of conservative treatments. Retain and submit these materials with the PA request or upon request for medical necessity review.

Definitions

Abdominoplasty: Typically performed for cosmetic purposes; involves removal of excess skin and fat from the pubis to the umbilicus or above and may include fascial plication of rectus diastasis and neoumbilicoplasty (ASPS, 2017).

Diastasis Recti: A vertical abnormal separation of the rectus abdominis muscles.

Functional or Physical Impairment: A deviation from normal tissue or organ function resulting in significantly limited or impaired capacity to move, coordinate actions, or perform physical activities (areas include physical/motor tasks, independent movement, basic life functions).

Suction-Assisted Lipectomy: Liposuction (SAL) is an outpatient procedure removing adipose tissue from the subcutaneous space to achieve body contouring.

Panniculectomy: Surgical removal of excess infraumbilical abdominal skin (pannus) to relieve symptoms such as intertrigo or functional impairment; may be functional or cosmetic.

Rectus diastasis repair: Surgical repair of separation of the rectus abdominis muscles, often performed during abdominoplasty to improve abdominal function and form.

Rhinophyma: A phymatous rosacea manifestation involving nasal tissue enlargement and deformity that may cause functional nasal obstruction.

Reconstructive surgery: Procedures intended to restore function and esthetics to defective or missing structures (includes hard/soft tissue procedures, prostheses, tissue-transfer techniques, reductions, revisions, and removals).

Cosmetic surgery: Procedures performed to improve appearance and not primarily to restore function; generally considered not reasonable and necessary under Medicare.

Medicare Determinations & NCD/LCD References

Name	Number/Identifier	Type
Breast Reconstruction Following Mastectomy	140.2	NCD
Multiple LCDs and LCAs referenced for cosmetic and reconstructive surgery (see code_groups list e.g., L33428, L39051, L39506, L35163, etc.)	See code_groups list (e.g., L33428, L39051, L39506, L35163, etc.)	NCD\|LCD
No NCD for free muscle or myocutaneous flap		NCD (none)

Revision History

10/01/2025removedLatest

Removed reference link to the UnitedHealthcare Commercial Medical Policy titled 'Cosmetic and Reconstructive Procedures Coverage Rationale'.

10/01/2025removedLatest

Removed content/language addressing autologous soft tissue and fat grafting (refer to Medicare Coverage Database for applicable guidelines).

10/01/2025revised

Policy Summary

PayerUnitedHealthcare

PolicyCosmetic and Reconstructive Procedures

Policy CodePolicy MMP022.14

Change TypeMultiple additions, removals, and revisions

Effective DateOct 1, 2025

Next Review Date

On This Page

AND causes ONE or more of

Inability to walk normally due to pannus size
Chronic pain
Ulceration created by the abdominal skin fold
Intertrigo dermatitis

Above symptoms present for at least three months and refractory to usual standard medical therapy>= 3 months

Preoperative photographs may be required to support justification

Additional criteria when performed following significant weight loss

Evidence that individual has maintained a stable weight for at least 6 months>= 6 months
Non-bariatric weight stability requirement
If weight loss is result of bariatric surgery, procedure not performed until at least 18 months after bariatric surgery and only when weight has been stable for at least the most recent 6 months>= 18 months (post-bariatric) and >= 6 months stable
Bariatric-specific timing

Not reasonable and necessary when performed primarily for

Improving appearance
Considered cosmetic
Repairing abdominal wall laxity or Diastasis Recti
Diastasis repair is separate indication
When performed in conjunction with abdominal or gynecological procedures (e.g., abdominal hernia repair, hysterectomy, obesity surgery) unless criteria for panniculectomy and abdominal lipectomy are met separately
Concurrent procedures generally not covered unless separate criteria met
Minimizing the risk of hernia formation or recurrence (considered not reasonable and necessary)
Policy states no evidence pannus contributes to hernia formation

Punch Graft Hair Transplant (no LCDs/LCAs)

Considered reconstructive and reasonable and necessary when performed for eyebrow(s) or symmetric hairline replacement following a burn injury, trauma, or tumor removal

Post-burn/trauma/tumor indication

Coverage determination guidance (overview)

UnitedHealthcare follows Medicare/CMS definitions and applies internal criteria when Medicare guidance is absent or flexible. Certain procedures may be considered cosmetic and therefore not reasonable and necessary; some require review to determine cosmetic vs reconstructive.

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High‑value evidence metrics

BODY‑Q longitudinal BCS cohortn=5,620; sustained HRQL and appearance improvement up to 10 years

Pooled complication rate after postbariatric BCS~31.5% (Marouf & Mortada 2021; n=3,834)

Bourry 2021 (orbital materials meta‑analysis)n=964; P(L/DL)LA, PP, titanium linked to less diplopia/enophthalmos vs autologous bone

Autologous cartilage orbital reconstruction review16 studies, n=259; harvest sites: conchal n=148, nasoseptal n=72; complications include sensory loss (n=27), diplopia (n=23), enophthalmos (n=7)

Hair transplant pooled outcomes (Stoneburner 2020)n pooled; micrograft survival ~85% (satisfaction ~90%); micro+mini survival ~93% (satisfaction ~98%)

Preoperative photographs of the pannus (may be required upon request)
Symptom history ≥ 3 months refractory to standard medical therapy (document dates and treatments)
Evidence of weight stability for ≥ 6 months when procedure follows significant weight loss; if post-bariatric, wait ≥ 18 months after bariatric surgery and stable weight for the most recent 6 months
Documentation of failed conservative therapies (e.g., topical treatments, wound care, medical management)

Documentation Required

Case-by-case review & CMS definition

In states/territories without applicable LCDs/LCAs, providers must apply the CMS cosmetic vs. reconstructive definition when preparing documentation and requesting coverage. Cases that are ambiguous or not specifically addressed by an LCD/LCA will be reviewed on a case-by-case basis. Retain all supporting documentation (photographs, clinical notes, therapy history) in the medical record and submit upon request.

Use the CMS definition to distinguish cosmetic versus reconstructive procedures where no LCD/LCA exists
Case-by-case medical necessity review will be performed for procedures not clearly addressed by policy; provide full supporting documentation upon request

Billing Rule

Claims accuracy & coding

Follow current CPT and CMS coding guidance when submitting claims. CPT code references in this policy are for informational purposes and do not guarantee payment. Ensure codes, modifiers, and documentation accurately reflect the procedure and medical necessity to avoid denials or recoupment.

Accurate CPT/HCPCS coding required; include appropriate modifiers and supporting documentation
CPT references in policy are informational only and not a guarantee of coverage/payment

Documentation Required

Referenced LCD / LCA identifiers

Referenced LCDs/LCAs applicable to billing and coverage determinations must be used when present. Providers should consult the CMS Medicare Coverage Database for the exact LCD/LCA identifiers and apply those guidance documents when preparing PA requests and claims.

Use the specific LCD/LCA identifiers listed in the Abdominal Lipectomy/Panniculectomy table and other procedure-specific tables when applicable
Reference LCD/LCA guidance for billing, coverage criteria, and documentation requirements

Revised coverage guidelines for states/territories with no LCDs/LCAs to allow preoperative photographs to support justification and updated list of indications not reasonable and necessary; replaced wording to reference 'abdominal lipectomy' instead of 'panniculectomy' in conjunction with other procedures unless criteria are met separately.

10/01/2025addedLatest

Added instruction to refer to the CMS definition of cosmetic and reconstructive surgery for coverage guidelines for states/territories with no LCDs/LCAs.

10/01/2025addedLatest

Added instruction to refer to InterQual CP: Procedures, Tissue Transfer (Flap) for coverage guidelines for various flap and tissue transfer procedures.

10/01/2025removedLatest

Removed language that reconstructive surgeries of head and neck are automatically reasonable and necessary for trauma, congenital anomalies, or tumors; replaced with requirement to refer to CMS definition and case-by-case review.

10/01/2025revisedLatest

Added instruction to refer to InterQual CP: Procedures, Tissue Transfer (Flap) for coverage guidelines for myocutaneous flaps.

10/01/2025removedLatest

Removed reference link to the UnitedHealthcare Commercial Medical Policy titled 'Cosmetic and Reconstructive Procedures'.

10/01/2025revisedLatest

Added language indicating otoplasty is considered cosmetic and therefore not reasonable and necessary.

10/01/2025revisedLatest

Added language indicating rhytidectomy is considered cosmetic and therefore not reasonable and necessary.

10/01/2025revisedLatest

Added language indicating subcutaneous injection of filling material is considered cosmetic and therefore not reasonable and necessary.

10/01/2025revisedLatest

Added language indicating suction assisted lipectomy of head and neck is considered cosmetic and therefore not reasonable and necessary.

10/01/2025revisedLatest

Added language indicating toe polydactyly reconstruction may be cosmetic; review required to determine if cosmetic or reconstructive.

10/01/2025revisedLatest

Added language indicating unlisted craniofacial and maxillofacial procedure may be cosmetic; review required to determine if cosmetic or reconstructive.

10/01/2025removedLatest

Removed CPT codes 11920, 11921, 11922, 15769, 15771, 15772, 15773, and 15774 from the Applicable Codes list.

10/01/2025removedLatest

Removed definition of 'Panniculectomy' from the Definitions section.