CurrentUnitedHealthcarePolicy CSOZZNJ.U

Cosmetic and Reconstructive Procedures (for New Jersey Only)

Defines when plastic/reconstructive surgical procedures are considered reconstructive (medically necessary) versus cosmetic for UnitedHealthcare members in New Jersey; applies to providers determining coverage and billing for related procedures.

Policy Summary

PayerUnitedHealthcare

PolicyCosmetic and Reconstructive Procedures (for New Jersey Only)

Policy CodePolicy CSOZZNJ.U

Change TypeClarification and coding updates (material)

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization and supporting documentation showing the physical or physiological abnormality and functional impairment; tissue transfer (flap) repairs should be reviewed using InterQual criteria.

SourceLink

POLICY UPDATE CHANGES

Updated list of applicable CPT codes to reflect annual edits and removed CPT 15819.

Removed reference link to the Medical Policy titled Pectus Deformity Repair (retired July 1, 2025).

Microtia repair is considered reconstructive even if no functional impairment is documented.

~100+procedure codes listed

1NJ only

InterQualInterQual referenced

1material changes

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Coverage Criteria: Reconstructive vs Cosmetic

Reconstructive (Medically Necessary)

Procedure is considered reconstructive and medically necessary when ALL of the following are met:

Reconstructive Criteria: There is documentation that the physical and/or physiological abnormality is causing a functional impairment that requires correction; the proposed treatment is of proven efficacy and is deemed likely to significantly improve or restore the individual's physiological function; and the procedure addresses an abnormality related to injury, illness, developmental abnormality, or congenital anomaly.

Microtia repair is considered reconstructive even if no functional impairment is documented.

Cosmetic (Not Medically Necessary)

Cosmetic (generally not covered) when the following applies:

Cosmetic Criteria: The procedure changes or improves appearance without significantly improving physiological function; procedures that correct an anatomical congenital anomaly without improving or restoring physiologic function are considered cosmetic; psychological or social consequences alone do not make a procedure reconstructive.

Tissue Transfer (Flap) Repair

Tissue transfer (flap) repair coverage:

Flap Repair: Tissue transfer (flap) repair is considered reconstructive and medically necessary in certain circumstances. Medical necessity clinical coverage criteria for tissue transfer (flap) repair are determined using InterQual Procedures, Tissue Transfer (Flap).

Refer to InterQual criteria for detailed clinical thresholds and prior authorization requirements.

Procedures performed solely to beautify or that do not meet reconstructive criteria are considered Cosmetic and are generally not covered. A procedure is classified as Cosmetic when it changes or improves appearance without significantly improving physiological function or when it corrects an anatomical congenital anomaly without improving or restoring physiologic function. Psychological or social consequences alone do not make a procedure reconstructive.

Certain procedure codes are identified in this policy as commonly Cosmetic and do not improve a functional, physical, or physiological impairment. Examples include multiple codes for subcutaneous injections of filling material (CPT 11950, 11951, 11952, 11954), punch grafts for hair transplant (15775, 15776), and a range of dermabrasion and chemical peel codes (e.g., 15780–15783, 15786–15789, 15792–15793). Several rhytidectomy codes (e.g., 15824, 15825, 15826, 15829) and additional items listed in the Applicable Codes tables are treated as Cosmetic in this policy and are generally not covered.

Applicable Codes and Coding Rules

Applicable CPT/HCPCS codes (may be Cosmetic or Reconstructive)mixed

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; 6.1 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 part thereof.
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 greater than 10 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.

1–10 of 93

1/10

Codes considered Cosmetic (do not improve functional/physiological impairment)CPTNot Covered

11950	Subcutaneous injection of filling material (collagen); 1 cc or less.
11951	Subcutaneous injection of filling material; 1.1 to 5.0 cc.
11952	Subcutaneous injection of filling material; 5.1 to 10.0 cc.
11954	Subcutaneous injection of material; over 10.0 cc filling.

Injectate volumes for autologous fat grafting — volume increments by anatomic site

Face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet25 cc injectate increments (CPT 15773/15774 apply: 25 cc or less, each additional 25 cc)

Trunk, breasts, scalp, arms, and/or legs50 cc injectate increments (CPT 15771/15772 apply: 50 cc or less, each additional 50 cc)

Coding reference (small-volume face/related sites)CPT 15773 — grafting of autologous fat to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate

Coding reference (large-volume trunk/breast sites)CPT 15771 — grafting of autologous fat to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization and InterQual Review: Certain reconstructive and tissue transfer (flap) procedures require prior authorization and may be reviewed using InterQual criteria. Providers must obtain prior authorization from UnitedHealthcare when the member’s plan requires it and submit documentation supporting medical necessity. For flap repair and other complex reconstructive procedures, coverage decisions will reference the InterQual CP: Procedures, Tissue Transfer (Flap).

InterQual review required for Tissue Transfer (Flap) and related reconstructive procedures where specified
Obtain prior authorization per UnitedHealthcare plan rules before scheduling procedure
Include a copy of the InterQual decision/supporting documentation when available

Documentation Required

Medical Necessity Documentation

Medical Necessity Documentation: Procedures billed as reconstructive must have documentation demonstrating a physical and/or physiological abnormality that is causing functional impairment and the proposed treatment is likely to significantly improve or restore physiological function. Medical records should clearly describe the functional impairment, prior conservative treatments (if applicable), and rationale for the chosen procedure. Note: Microtia repair is considered reconstructive even if functional impairment documentation is limited.

Key Definitions

Cosmetic Surgery — definition (N.J.A.C. 10.54-5.3)

DefinitionCosmetic Surgery: surgery performed solely to beautify an individual and which has no significant redeeming medical necessity (N.J.A.C. 10.54-5.3).

Coverage implicationProcedures performed solely to beautify or that do not meet reconstructive criteria are generally considered Cosmetic and not covered.

Scope noteRefer to state and contractual requirements for plan‑specific definitions and applicability.

Functional or Physical Impairment — definition

DefinitionFunctional or Physical Impairment: deviation from normal tissue, organ, or physiological function causing significant limitation in movement, coordination, or basic life activities (Medicare, 2023).

Documentation requirement

Background

Reconstructive procedures are intended to address a physical or physiological abnormality resulting from injury, illness, developmental anomaly, or congenital defect with the goal of improving or restoring physiologic function. Under this policy, a procedure is considered reconstructive and medically necessary when documentation shows the abnormality is causing a functional impairment, the proposed treatment is of proven efficacy and likely to significantly improve or restore physiological function, and the procedure addresses an abnormality related to injury, illness, development, or congenital anomaly. (Note: the policy explicitly treats repair of microtia as reconstructive even if functional impairment is not documented.)

Revision History and Policy Changes

2025-07-01related_policy_removed

Removed reference link to the Medical Policy titled 'Pectus Deformity Repair (for New Jersey Only)' (retired July 1, 2025).

2025-01-01codes_updatedLatest

Updated list of applicable CPT codes to reflect annual edits and removed CPT 15819.

Policy Summary

PayerUnitedHealthcare

PolicyCosmetic and Reconstructive Procedures (for New Jersey Only)

Policy CodePolicy CSOZZNJ.U

Change TypeClarification and coding updates (material)

Effective DateJan 1, 2025

Next Review DateN/A

SourceLink

On This Page

Document the physical/physiological abnormality and the specific functional impairment
Provide objective findings, diagnostic testing, and prior treatment history supporting the need for surgery
Explain how the procedure is expected to improve physiological function

Denial Risk

Cosmetic Procedures Generally Not Covered

Cosmetic Exclusion Risk: Procedures that change or improve appearance without significantly improving physiological function are generally considered Cosmetic and are not covered. Correction of an anatomical congenital anomaly that does not improve physiologic function is typically cosmetic. Psychological or social impacts alone do not make a procedure reconstructive. Review of specific procedure codes is required to determine Cosmetic versus Reconstructive classification.

Procedures not meeting reconstructive criteria may be denied as Cosmetic
Examples of codes that may be Cosmetic (review required): 11920–11922, 11960, 14000–14021 (see Applicable Codes for full list)
When cosmetic exclusion is suspected, provide documentation demonstrating physiologic functional impairment to support medical necessity

Note

Provider Action Checklist

Provider Action Summary: Obtain prior authorization when required, use InterQual criteria for eligible procedures (e.g., Tissue Transfer/Flap), and supply complete medical necessity documentation showing physical/physiological abnormality causing functional impairment. Anticipate denial risk for procedures that are cosmetic in nature and be prepared to submit supporting clinical evidence to justify reconstructive classification.

Follow UnitedHealthcare prior authorization processes and timelines
Reference InterQual CP where indicated (Tissue Transfer/Flap)
Ensure documentation addresses functional impairment and treatment rationale to avoid cosmetic denial

Medical necessity requires documentation that the abnormality is causing a functional impairment that requires correction.

Exclusion notePsychological or social consequences alone do not make a procedure reconstructive.

Microtia — definition and policy treatment

DefinitionMicrotia: congenital underdevelopment of the external ear (birth defect where the external ear is small and not formed properly).

Policy stanceMicrotia repair is considered Reconstructive under this policy even if no functional impairment is documented.

Coverage implicationTreat microtia repair as medically necessary reconstructive surgery when indicated by congenital anomaly, per policy clarification.

Reconstructive Surgery — definition and medical necessity

DefinitionReconstructive Surgery: repair or reconstruction of changes due to trauma, infection, or surgery where need for correction demonstrates significant medical necessity (N.J.A.C. 10.54-5.3).

Medical necessity criteriaProcedure is reconstructive and medically necessary when: 1) the abnormality causes a functional impairment requiring correction; 2) proposed treatment is of proven efficacy and likely to significantly improve or restore physiological function; 3) procedure addresses abnormality from injury, illness, development abnormality, or congenital anomaly.

Microtia exceptionNote: Microtia repair is explicitly considered reconstructive even if functional impairment is not documented.