Cosmetic and Reconstructive Procedures (for Ohio Only)
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Policy governing coverage determinations for cosmetic and reconstructive surgical procedures for UnitedHealthcare members in the state of Ohio; applies to providers and claims reviewers evaluating medical necessity and coding for such procedures.
Replaced language indicating 'jaw reconstruction is considered medically necessary in certain circumstances' with 'jaw reconstruction is considered reconstructive and medically necessary in certain circumstances'.
Added reference to the InterQual CP: Procedures, Orthognathic Surgery and removed references to InterQual CP bone augmentation and maxillary osteotomy criteria.
Added language clarifying that medical records documentation may be required to assess whether the member meets clinical criteria and listing examples of required documentation.
Updated definitions for Cosmetic Procedures, Functional Impairment, and Reconstructive Procedures.
Coverage Criteria
General Reconstructive Criteria
A procedure is considered reconstructive and medically necessary when ALL of the following are met:
Microtia repair is considered reconstructive, although no Functional Impairment may be documented.
Tissue Transfer (Flap) Repair
Flap repair is considered reconstructive and medically necessary in certain circumstances when external criteria are met:
Refer to InterQual® for specific clinical logic and indications; use InterQual as the primary medical/surgical criteria when requesting authorization.
Jaw Reconstruction
Jaw reconstruction is considered reconstructive and medically necessary in certain circumstances when external criteria are met:
Refer to InterQual® for the procedure-specific clinical logic and indications; InterQual is the primary criteria source for authorization.
General medical necessity criteria
Covered when services meet reconstructive definition and applicable clinical criteria (see InterQual or UnitedHealthcare guidelines) and documentation supports medical necessity.
Exact InterQual criteria must be consulted for procedure-specific requirements. Medical records documentation (relevant history, physical exam, and pertinent diagnostic test results) must fully support the requested service, be legible, maintained in the patient's record, and made available upon request.
Procedures and codes explicitly identified as cosmetic are those that do not improve a functional, physical, or physiological impairment and are reviewed under Ohio Administrative Code Rule 5160-2-03. When a procedure or code is categorized as cosmetic, it is treated under the policy’s cosmetic exclusions and may be excluded from coverage unless the member’s benefit plan or specific clinical documentation demonstrates a reconstructive indication. Examples of codes flagged for potential cosmetic review appear in the policy’s coding lists and must be evaluated in the clinical context of the request.
Procedures performed solely to reshape or enhance appearance without improving physiological function are cosmetic and are excluded from reconstructive coverage. Reconstructive procedures, by contrast, are intended to correct a physical or physiological abnormality to improve or restore physiological function; services that only alter aesthetic appearance do not meet that reconstructive definition and therefore are not covered under reconstructive criteria unless plan requirements or documented functional impairment indicate otherwise.
The policy identifies specific CPT/HCPCS codes that are considered cosmetic and therefore not medically necessary when done solely for aesthetic purposes. These include, but are not limited to, codes for subcutaneous filler injections, hair transplant punch grafts, dermabrasion and chemical peels, rhytidectomy, and multiple excision/lipectomy and abrasion codes. When these codes are billed, reviewers should determine whether the documented indication meets the reconstructive definition and applicable clinical criteria; if not, the service is handled as cosmetic and may be denied.
The policy explicitly lists several codes as examples of services that are considered cosmetic and therefore not medically necessary when performed solely for aesthetic benefit. Examples called out in the coding section include CPT 15837, 15838, 15839, 15876, 17380, 21270, 69090, 69300 and HCPCS J0591. Presence of these codes on a claim should prompt review of the medical record to confirm whether a reconstructive indication exists; absent such documentation, the codes are not covered as medically necessary.
Coding
| 11920 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin; 6.0 sq cm or less |
| 11921 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin; 6.1 to 20.0 sq cm |
| 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 |
| 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 |
| 14301 | Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm |
| 15570 | Formation of direct or tubed pedicle, with or without transfer; trunk |
| 15837 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand. |
| 15838 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad. |
| 15839 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area. |
| 15876 | Suction assisted lipectomy; head and neck. |
| 17380 | Electrolysis epilation, each 30 minutes. |
| 21270 | Malar augmentation, prosthetic material. |
| 69090 | Ear piercing. |
| 69300 | Otoplasty, protruding ear, with or without size reduction. |
| J0591 | Injection, deoxycholic acid, 1 mg |
Provider Actions & Authorization
InterQual referenced criteria for certain reconstructive procedures
Certain reconstructive procedures (for example, tissue transfer/flap repair and jaw reconstruction) are subject to medical necessity clinical coverage criteria that reference InterQual. Providers must consult the InterQual CP referenced for the specific procedure when preparing authorization requests.
- Flap repair: follow InterQual CP: Procedures, Tissue Transfer (Flap).
- Jaw reconstruction: follow the referenced InterQual criteria for Bone Augmentation (Maxilla), Reconstruction (TMJ), or Orthognathic Surgery as applicable.
Use InterQual criteria as primary source for prior authorization
Use InterQual as the primary medical/surgical criteria when requesting authorization; if InterQual does not have applicable criteria for the requested service, UnitedHealthcare may use its own approved guidelines.
- UnitedHealthcare uses InterQual for primary medical/surgical criteria in benefit administration.
- If InterQual lacks applicable criteria, UnitedHealthcare may apply its Medical Policies, Coverage Determination Guidelines, or Utilization Review Guidelines approved by Ohio Medicaid.
Prior authorization submission expectations
Submit prior authorization requests that reference the applicable InterQual criteria and include clinical documentation demonstrating how the member meets those criteria.
- Reference the specific InterQual CP (e.g., Tissue Transfer (Flap), Orthognathic Surgery) on the authorization request.
- Include relevant clinical findings, diagnostic test results, and any prior conservative treatments to show criteria are met.
Expectation to provide medical records during review
Provide complete medical record documentation upon request; documentation may be required to assess whether the member meets clinical criteria and to complete the review.
- Documentation may be requested during utilization review and its presence does not guarantee coverage.
- Ensure records are available and submitted when UnitedHealthcare requests them during the authorization or claims review process.
Medical record documentation requirements (legible, available on request)
Maintain legible medical record documentation that fully supports the medical necessity of the requested services, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Documentation must be legible, maintained in the patient's medical record, and made available upon request.
- Include specific exam findings, diagnostic imaging or test results, and chronology relevant to the reconstructive need.
Examples of documentation UnitedHealthcare may request
Be prepared to provide any additional documentation UnitedHealthcare requests to determine whether the member meets clinical criteria; examples include history, focused physical exam findings, and pertinent diagnostic studies.
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage.
- Examples of required documentation include relevant medical history, physical examination, and results of diagnostic tests or procedures.
Denial risk for insufficient medical record documentation
Failure to provide medical record documentation that supports medical necessity may lead to denial or an incomplete review; ensure records submitted clearly show how criteria are met.
- Lack of documentation (history, exam, diagnostic tests) may trigger denial or further review.
- Timely submission of complete records reduces the risk of denial for insufficient information.
Risk of noncoverage for procedures classified as cosmetic
Do not submit procedures or codes that are classified as cosmetic under Ohio Administrative Code Rule 5160-2-03 as reconstructive; procedures identified as cosmetic in the policy’s code lists risk noncoverage.
- Examples of codes identified as cosmetic are listed in the policy and are considered not medically necessary when performed solely for aesthetic benefit.
- Refer to OAC Rule 5160-2-03 and the policy’s cosmetic code list before seeking coverage for procedures primarily intended to enhance appearance.
Documentation-related denial risk if records are incomplete or not provided
If requested, provide complete medical records that fully support medical necessity; failure to submit such documentation may result in denial or inability to determine coverage.
- Documentation must fully support why the service is reconstructive and how clinical criteria are met.
- Records must be legible, in the patient’s record, and made available upon request to avoid coverage determination delays or denials.
Definitions
Background
Reconstructive procedures are performed to correct a physical and/or physiological abnormality related to injury, illness, developmental abnormality, or congenital anomaly with the primary intent to improve or restore physiological function. Under this policy, a procedure is considered reconstructive and medically necessary only when there is documentation that the abnormality is causing a Functional Impairment requiring correction and the proposed treatment is of proven efficacy and likely to significantly improve or restore physiological function. The policy notes that certain procedures (for example, microtia repair) are considered reconstructive even when functional impairment is not documented, and that procedure-specific clinical criteria (including referenced InterQual criteria for some surgeries) must be met where applicable.
Revision History
Revised coverage rationale for jaw reconstruction to state it is 'reconstructive and medically necessary in certain circumstances' and updated references to InterQual criteria (added Orthognathic Surgery CP; removed Bone Augmentation, Mandible and Maxillary Osteotomy criteria).
Added and clarified medical records documentation requirements stating documentation may be required to assess clinical criteria, must fully support medical necessity, include relevant history, exam, and test results, be legible, maintained in the patient's record, and made available upon request.
Updated definitions for Cosmetic Procedures, Functional Impairment, and Reconstructive Procedures.
Updated the References/supporting information and archived previous policy version CS027OH.D.
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