CurrentUnitedHealthcarePolicy CSOZ7KY.11

Cosmetic and Reconstructive Procedures (for Kentucky Only)

State-specific UnitedHealthcare medical policy for Kentucky defining when procedures are considered reconstructive (medically necessary) versus cosmetic (generally not covered), with lists of CPT/HCPCS codes that may be cosmetic or require review and references to InterQual criteria for detailed clinical coverage.

Policy Summary

PayerUnitedHealthcare

PolicyCosmetic and Reconstructive Procedures (for Kentucky Only)

Policy CodePolicy CSOZ7KY.11

Change TypeCode updates + removal of related policy link

Effective DateJan 1, 2025

Next Review Date

Key ActionProviders must document that the physical or physiological abnormality is causing a Functional Impairment requiring correction to meet reconstructive criteria (except microtia where impairment may not be documented).

POLICY UPDATE CHANGES

Applicable CPT codes updated to reflect annual edits; code 15819 removed.

Removed reference/link to the Medical Policy titled Pectus Deformity Repair (for Kentucky Only) (retired Jul 1, 2025).

manyApplicable CPT/HCPCS codes listed

1State-specific applicability (Kentucky only)

Coverage Summary

This is the UnitedHealthcare state-specific medical policy for Kentucky that defines when procedures are considered reconstructive (medically necessary) versus cosmetic (generally not covered).

Reconstructive vs Cosmetic Criteria (Medical Necessity)

Reconstructive Procedures (Medically Necessary)

A procedure is considered Reconstructive and medically necessary when all of the following criteria are met:

ALL of the following

The proposed treatment is of proven efficacy and is deemed likely to significantly improve or restore the individual's physiological function
There is documentation that the physical abnormality and/or physiological abnormality is causing a Functional Impairment that requires correction
Note: Microtia repair is considered Reconstructive although no Functional Impairment may be documented
explicit exception

Tissue Transfer (Flap) Repair

Flap repair is considered Reconstructive and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to InterQual criteria.

Meet InterQual criteria for flap repair (see linked InterQual CP: Procedures)

Jaw Reconstruction

Jaw reconstruction is considered medically necessary in certain circumstances; refer to InterQual CP: Procedures for specific criteria

Procedures referenced (InterQual)

Bone Augmentation; Mandible
Bone Augmentation; Maxilla
Reconstruction; Temporomandibular Joint (TMJ)
Osteotomy, Maxillary Buttress, +/- Mid Palatal Osteotomy

CPT / HCPCS Codes

Codes that may be Cosmetic; review required to determine Cosmetic vs ReconstructiveCPT|HCPCS

11920	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less
11921	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6. to 20.0 sq cm
11922	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or thereof (List separately in addition part)
11950	Subcutaneous injection of material (e.g., collagen); 1 cc or less filling
11951	Subcutaneous injection of filling material (e.g., collagen); 1.1 to 5.0 cc
11952	Subcutaneous injection of material (e.g., collagen); 5.1 to 10.0 cc filling
11954	Subcutaneous injection of filling material (e.g., collagen); over 10.0 cc
11960	Insertion of tissue expander(s) for other than breast; including subsequent expansion
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

1–10 of 95

1/10

Codes considered Cosmetic (do not improve a Functional, Physical, or physiological Impairment)CPTNot Covered

11950	Subcutaneous injection of material (e.g., collagen); 1 cc or less filling
11951	Subcutaneous injection of filling material (e.g., collagen); 1.1 to 5.0 cc
11952	Subcutaneous injection of material (e.g., collagen); 5.1 to 10.0 cc filling
11954	Subcutaneous injection of filling material (e.g., collagen); over 10.0 cc
15775	Punch for hair transplant; 1 to 15 punch grafts
15776	Punch graft for hair transplant; more than 15 punch grafts
15780	Dermabrasion; total face
15781	Dermabrasion; segmental, face
15782	Dermabrasion; regional, other than face
15783	Dermabrasion; superficial, any site (e.g., tattoo removal)

1–10 of 24

1/3

This policy version includes a material change: the list of applicable CPT codes was updated for annual edits and code 15819 was removed.

Listed CPT/HCPCS codes may be cosmetic or reconstructive and therefore require review of clinical documentation to determine coverage and reimbursement.

Provider Actions & Documentation Requirements

Documentation Required

Document Functional Impairment for Reconstructive Coverage

Providers must document that the physical and/or physiological abnormality is causing a Functional Impairment that requires correction to meet reconstructive criteria. Note: Microtia repair is considered reconstructive even if a Functional Impairment is not documented.

Exception: Microtia repair does not require documented functional impairment.

Documentation Required

Use InterQual for Clinical Criteria

For flap repair, jaw reconstruction, and other referenced procedures, providers must meet InterQual clinical criteria; UnitedHealthcare uses InterQual as the primary medical/surgical criteria for these procedures. See InterQual CP: Procedures for specific medical necessity requirements for tissue transfer (flap) repair and for jaw reconstruction procedures such as bone augmentation (mandible/maxilla), TMJ reconstruction, and maxillary osteotomy.

Billing Rule

Code Review Required

The listed CPT and HCPCS codes include services that may be considered either cosmetic or reconstructive. A review of the member's clinical documentation is required to determine whether a given code is being used for reconstructive (medically necessary) versus cosmetic purposes and to establish coverage and reimbursement.

Definitions & Background

Reconstructive procedures are performed to treat a physical and/or physiological abnormality related to an injury, illness, developmental abnormality, or congenital anomaly with the goal to improve or restore physiological function; cosmetic procedures reshape or enhance appearance without improving physiological function.

A procedure meets reconstructive (medically necessary) criteria when it is of proven efficacy and likely to significantly improve or restore physiological function and when there is documentation that the abnormality is causing a Functional Impairment that requires correction (with an explicit exception that microtia repair is considered reconstructive even if a functional impairment is not documented).

For procedures such as flap repair and jaw reconstruction, UnitedHealthcare directs reviewers and providers to the applicable InterQual clinical criteria to determine medical necessity.

Term	Definition
Cosmetic Surgery	Cosmetic Surgery is performed to reshape normal structures of the body in order to enhance an individual's appearance and self-esteem.
Functional or Physical Impairment	A Functional or Physical or physiological Impairment causes deviation from the normal function of a tissue or organ resulting in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in physical and motor tasks; independent movement; or performing basic life functions.
Microtia	Microtia is a birth defect of a baby's ear in which the external ear is small and not formed properly; the defect can vary in severity and usually affects appearance but not the internal ear structures.
Reconstructive Surgery	Surgery or other procedures related to an injury, sickness, or congenital anomaly where the primary result of the procedure is not a changed or improved physical appearance.