ModifiedUnitedHealthcarePolicy CS027OH.D

Cosmetic and Reconstructive Procedures (for Ohio Only)

Policy governing coverage determinations for cosmetic versus reconstructive plastic and reconstructive procedures for members in Ohio, including definitions, applicable codes, and references to clinical criteria sources. Affects providers requesting coverage for procedures in Ohio.

Policy Summary

PayerUnitedHealthcare

PolicyCosmetic and Reconstructive Procedures (for Ohio Only)

Policy CodePolicy CS027OH.D

Change TypeAdded InterQual guidance and CPT codes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and follow InterQual criteria for tissue transfer (flap) and jaw reconstruction decisions.

SourceLink

POLICY UPDATE CHANGES

Added language to indicate jaw reconstruction is considered medically necessary in certain circumstances; for medical necessity clinical coverage criteria, refer to the InterQual CP: Bone Augmentation, Maxilla; Bone Augmentation, Mandible; Reconstruction, Temporomandibular Joint (TMJ).

Added CPT codes 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, and 15876 to Applicable Codes.

Updated definition of 'Microtia'.

Updated References section to reflect the most current information.

Ohioapplies only to

InterQualInterQual referenced

manycodes listed

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Coverage Criteria

Reconstructive Procedures

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

Reconstructive criteria: Documentation that the physical and/or physiological abnormality is causing a Functional Impairment that requires correction.

Reconstructive criteria: The proposed treatment is of proven efficacy and is deemed likely to significantly improve or restore the individual's physiological function.

Reconstructive criteria: Note: Microtia repair is considered reconstructive, although no Functional Impairment may be documented.

Do not remove microtia exception

Procedures governed by InterQual

Certain procedures use external clinical criteria sets:

Tissue transfer (flap): Flap repair is considered reconstructive and medically necessary in certain circumstances; for medical necessity clinical coverage criteria, refer to the InterQual CP: Procedures, Tissue Transfer (Flap).

Refer to InterQual for specific criteria

Jaw reconstruction is considered medically necessary in certain circumstances; for medical necessity clinical coverage criteria, refer to the InterQual CP: Procedures for Bone Augmentation (Maxilla, Mandible) and Reconstruction, TMJ; also see Osteotomy, Maxillary Buttress (+/- Mid Palatal Osteotomy).

Refer to InterQual for specific criteria

Reconstructive Procedures – InterQual-based criteria

Coverage for reconstructive procedures and jaw reconstruction

InterQual-directed criteria: Jaw reconstruction (Bone Augmentation: Maxilla and Mandible; Reconstruction, TMJ; Osteotomy, Maxillary Buttress +/- Mid Palatal Osteotomy) is considered medically necessary in certain circumstances; medical necessity determinations follow the InterQual CP criteria referenced by UnitedHealthcare.refer to InterQual

Use InterQual CP: Bone Augmentation, Maxilla; Bone Augmentation, Mandible; Reconstruction, TMJ for specific clinical criteria.

Codes that are explicitly listed as cosmetic are considered not reconstructive because they do not improve a functional, physical, or physiological impairment. When a procedure or supply is identified in the policy as cosmetic, it is excluded from reconstructive coverage determinations and is at risk for denial unless documentation demonstrates a covered functional impairment or other coverage criteria are met.

See the policy code lists for specific examples of codes categorized as cosmetic (for example, dermabrasion, injectable fillers, and HCPCS code J0591), which are described in the policy as not improving physiologic function and therefore considered cosmetic.

Procedures performed solely to reshape or enhance appearance without improving physiological function are classified as cosmetic and excluded from reconstructive coverage. The policy distinguishes reconstructive objectives (restoration or improvement of physiologic function) from cosmetic goals (appearance enhancement), and coverage decisions follow that distinction.

Providers should document physiological impairment and the expected functional benefit of treatment when requesting coverage for procedures that might otherwise be considered cosmetic; absent such documentation, services intended only to improve appearance will be denied as cosmetic.

The policy expressly lists specific procedures and service codes that are considered cosmetic and therefore not medically necessary when performed solely to improve appearance. Examples include injectable filler and collagen injection codes (e.g., subcutaneous filling material codes 11950–11954), dermabrasion and chemical peel codes (e.g., 15780–15783, 15788–15793), and rhytidectomy codes (e.g., 15824–15829).

These listed codes do not, by policy definition, improve a functional, physical, or physiological impairment and are treated as cosmetic; clinicians must provide supporting documentation of physiologic benefit to justify coverage where applicable.

Services billed with HCPCS J0591 (deoxycholic acid injection, 1 mg) are classified in this policy as cosmetic because they do not improve a functional, physical, or physiological impairment. As a result, treatments utilizing J0591 are considered not medically necessary when performed solely for appearance reshaping.

Claims or prior authorization requests involving J0591 should include clear clinical justification demonstrating restoration or improvement of physiological function if coverage is being sought; absent such justification the service is at risk for denial as cosmetic.

Applicable Codes and Coding Lists

Codes listed (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 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

1–10 of 103

1/11

Cosmetic HCPCS CodesHCPCSNot Covered

J0591

Injection, deoxycholic acid, 1 mg

Applicable CPT Codes (added)CPT

15832	Excision, excessive skin and subcutaneous tissue; thigh
15833	Excision, excessive skin and subcutaneous tissue; leg
15834	Excision, excessive skin and subcutaneous tissue; hip
15835	Excision, excessive skin and subcutaneous tissue; buttock
15836	Excision, excessive skin and subcutaneous tissue; arm
15837	Excision, excessive skin and subcutaneous tissue; forearm or hand
15838	Excision, excessive skin and subcutaneous tissue; submental fat pad
15839	Excision, excessive skin and subcutaneous tissue; other area
15876	Suction assisted lipectomy; head and neck

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization and InterQual Use

Prior authorization is required as indicated by Ohio Administrative Code and UnitedHealthcare procedures. Requests for services that are stated as unproven or subject to coverage or quantity limits will be evaluated for medical necessity using Ohio Administrative Code 5160-101. UnitedHealthcare uses InterQual® for primary medical/surgical criteria; when InterQual® criteria apply (for example certain reconstructive and jaw reconstruction procedures) prior authorization determinations will be guided by those InterQual® criteria.

Prior authorization requirements are governed by federal, state (OAC), and contractual terms — reference plan terms.
InterQual® criteria are used to evaluate medical necessity for reconstructive and jaw reconstruction procedures.

Documentation Required

Documentation of Functional Impairment

Documentation must demonstrate a physical and/or physiological abnormality that is causing a Functional or Physical Impairment and show that the proposed treatment is primarily restorative and likely to significantly improve or restore physiological function.

Definitions

Reconstructive Surgery — definition (inv-20)

DefinitionSurgery or other procedures related to an injury, sickness, or congenital anomaly where the primary result is restoration or improvement of physiologic function (not improved appearance).

IntentPerformed to correct a physical and/or physiological abnormality and to improve or restore physiologic function.

Documentation noteMedical necessity requires documentation that the abnormality causes a functional impairment and that the proposed treatment is likely to restore or significantly improve physiological function.

Cosmetic Surgery — definition (inv-21)

DefinitionSurgery performed to reshape normal structures of the body to enhance appearance and self‑esteem; does not improve physiological function.

Coverage implication

Background

Reconstructive procedures are intended to treat a physical or physiological abnormality that results from injury, illness, developmental abnormality, or a congenital anomaly, with the goal of improving or restoring physiologic function. This contrasts with cosmetic procedures, which are performed to reshape or enhance appearance without improving physiological function.

Under this policy, examples of reconstructive indications include restoration of function after trauma, correction of congenital defects (for example, microtia is considered reconstructive even if functional impairment is not documented), and procedures that are proven and likely to significantly improve physiologic function.

Revision History

2026-01-01material_changeLatest

Added language clarifying jaw reconstruction may be medically necessary in certain circumstances and directed reviewers to InterQual CP criteria for Bone Augmentation (Maxilla and Mandible) and TMJ reconstruction.

2026-01-01material_change

Added CPT codes 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, and 15876 to the list of applicable codes.

2026-01-01non_material_update