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    v1.0.30
    OpenPayerPolicy UpdatesPlastic/Reconstructive SurgeryUnitedHealthcare Plastic Surgery Coverage | OpenPa…
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    CurrentUnitedHealthcarePolicy BIP169.P

    Cosmetic, Reconstructive, or Plastic Surgery

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    Coverage and prior authorization requirements for cosmetic, reconstructive, and plastic surgery services for UnitedHealthcare California HMO and EPO/POS members.

    Policy Summary
    PayerUnitedHealthcare
    PolicyCosmetic, Reconstructive, or Plastic Surgery
    Policy CodePolicy BIP169.P
    Change TypeRoutine reviewno coverage guideline change
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionObtain preauthorization from the member’s network medical group or UnitedHealthcare before reconstructive or cosmetic surgery.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    CAApplicable state
    RequiredAuthorization
    3Covered-benefit sections
    All servicesMedical necessity
    Routine reviewPolicy history

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Covered and Excluded Services

    Covered reconstructive surgery

    Reconstructive surgery is covered when it meets applicable federal or California mandated requirements or meets medical necessity criteria.

    Qualifying reconstructive indication: The procedure corrects or repairs an abnormal body structure caused by a congenital defect, developmental abnormality, trauma, infection, tumor, or disease.
    Covered purpose: The procedure is needed to improve function or to create a normal appearance to the extent possible.
    Examples of covered reconstructive services: Examples include eligible eyelid or brow procedures, breast reconstruction or correction of breast asymmetry, breast reduction, authorized multi-stage reconstruction, panniculectomy, jaw reconstruction after tumor or cancer removal, scar contracture release, cleft palate or cleft lip repair, gynecomastia correction, hypospadias correction, microtia correction, and polydactyly treatment.

    Examples are not an exhaustive list and may require review under a related medical policy.

    Women’s Health and Cancer Rights Act reconstruction benefits

    For a participant or beneficiary receiving mastectomy benefits who elects breast reconstruction, applicable group health plans must provide the following coverage.

    Mastectomy-related reconstruction coverage: Coverage includes all stages of reconstruction of the breast on which mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and physical complications of all stages of mastectomy, including lymphedema.

    Coverage is determined in consultation with the attending physician and patient and may remain subject to applicable deductibles and coinsurance.

    California mandated reconstructive coverage

    California reconstructive surgery coverage applies when the service is necessary to achieve a qualifying reconstructive purpose.

    California reconstructive surgery: The surgery is necessary to correct or repair abnormal structures caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease and is intended to improve function or create a normal appearance to the extent possible.

    Medically necessary dental or orthodontic services integral to cleft palate reconstructive surgery are included; cleft palate may include cleft lip and associated craniofacial anomalies.

    California market plan enhancements

    Additional California market-plan benefits and related review requirements apply.

    California market enhancements: Members may have benefits for transgender reassignment surgery; all breast reduction surgeries require medical necessity review; and additional covered reconstructive services are described in the policy’s covered-benefit examples.

    Refer to the Gender Dysphoria Treatment and Breast Reduction Surgery policies as applicable.

    Elective enhancements related to hereditary pattern baldness, sexual performance, athletic performance, cosmetic purposes, anti-aging, or mental performance are not covered.

    Surgical procedures intended to correct the consequences of normal aging are not covered.

    Surgical removal of common, benign skin lesions is not covered when the lesions are not caused by a congenital defect, developmental abnormality, trauma, infection, tumor, or disease.

    Tattoo removal, dermabrasion, and liposuction are not covered.

    Reconstructive surgery is not medically necessary for coverage when another more appropriate surgical procedure has been offered to the member, as determined or defined by UnitedHealthcare or its designee.

    Reconstructive surgery is not medically necessary for coverage when only minimal improvement in the member’s appearance is expected.

    Authorization and Denial Requirements

    Prior Authorization

    Preauthorization Required Before Surgery

    Obtain preauthorization before performing reconstructive or cosmetic procedures. Preauthorization must be obtained through the member’s network medical group or UnitedHealthcare, consistent with standards of care practiced by physicians specializing in reconstructive surgery.

    • Applies to reconstructive and cosmetic procedures.
    • Confirm the applicable authorization pathway before surgery.
    Documentation Required

    Qualified Clinical Review for California Requests

    For California requests governed by Health and Safety Code §1367.63, an initial authorization denial must be made by a qualified licensed physician competent to evaluate the specific clinical issues involved. Requests submitted by a podiatrist or oral and maxillofacial surgeon may be reviewed by a similarly licensed, clinically competent individual.

    Reconstructive Surgery Overview

    Reconstructive surgery corrects or repairs abnormal body structures caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It may be intended to improve function or create a normal appearance to the extent possible.

    Key Policy Definitions

    Reconstructive surgery
    DefinitionSurgery performed to correct or repair abnormal structures of the body.
    Causes addressedThe abnormal structures may be caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease.
    PurposeThe surgery is performed to improve function or to create a normal appearance, to the extent possible.
    Cosmetic surgery
    DefinitionSurgery performed to alter or reshape normal structures of the body.
    Structures treatedThe structures treated are normal body structures.
    Purpose
    Policy Summary
    PayerUnitedHealthcare
    PolicyCosmetic, Reconstructive, or Plastic Surgery
    Policy CodePolicy BIP169.P
    Change TypeRoutine reviewno coverage guideline change
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionObtain preauthorization from the member’s network medical group or UnitedHealthcare before reconstructive or cosmetic surgery.
    SourceLink
    On This Page
    Covered and Excluded ServicesAuthorization and Denial RequirementsReconstructive Surgery OverviewKey Policy Definitions
  1. Do not issue an initial denial through an unqualified non-physician reviewer.
  2. The reviewer must be competent to evaluate the specific care requested.
    3. Denial Risk

    Alternative Procedure or Minimal Expected Improvement

    Prior authorization and utilization review may support denial when an appropriate alternative procedure has been offered or when the proposed procedure is expected to provide only minimal improvement in appearance.

    • An alternative procedure must be more appropriate and offered to the member as determined or defined by UnitedHealthcare or its designee.
    • Minimal expected improvement may support denial when the procedure offers only minimal improvement in the member’s appearance.
    Denial Risk

    Cosmetic and Elective Services

    Do not represent elective or cosmetic services as covered reconstructive care unless coverage criteria are met. Elective enhancements related to hereditary pattern baldness, sexual or athletic performance, cosmetic or anti-aging purposes, and mental performance are not covered, along with procedures correcting normal aging, removal of common benign skin lesions not caused by a qualifying condition, tattoo removal, dermabrasion, and liposuction.

    • Refer to the member’s Evidence of Coverage or Schedule of Benefits for additional exclusions and limitations.
    • Expect denial risk for elective, cosmetic, anti-aging, athletic-performance, sexual-performance, or mental-performance services.
    Billing Rule

    Services Without Authorization May Be Denied

    Payment may be denied for procedures performed without prior authorization. Complete and document the required authorization before the service is performed.

    • The denial condition applies to procedures performed without prior authorization.
    The surgery is performed to improve appearance.
    Congenital defect
    DefinitionA condition of prenatal origin.
    When presentThe condition is present at birth.
    Potential impactIt may affect an infant's health, development, or survival.
    Cleft palate
    DefinitionA condition that may include cleft palate.
    Associated conditionIt may include cleft lip.
    Related anomaliesIt may include other craniofacial anomalies associated with cleft palate.