ModifiedUnitedHealthcarePolicy CS027KY.12

Cosmetic and Reconstructive Procedures (for Kentucky Only)

Defines medical necessity and coverage stance for cosmetic versus reconstructive surgical procedures for UnitedHealthcare members in Kentucky and lists applicable procedure and supply codes for reference.

Policy Summary

PayerUnitedHealthcare

PolicyCosmetic and Reconstructive Procedures (for Kentucky Only)

Policy CodePolicy CS027KY.12

Change TypeDefinitions updatedCPT codes added

Effective DateMay 1, 2026

Next Review Date

Key ActionFollow UnitedHealthcare prior authorization processes and InterQual criteria for tissue transfer (flap) and specified jaw reconstruction procedures when prior authorization is required.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Microtia'.

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

Updated References section to reflect the most current information.

state-specificapplies only to Kentucky

2procedure categories defined

9CPT codes added

multiplecode lists provided

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Medically necessary (Reconstructive)

Reconstructive Procedures

Reconstructive criteria: There is documentation that the physical abnormality and/or physiological abnormality is causing a Functional Impairment that requires correction; and the proposed treatment is of proven efficacy and is deemed likely to significantly improve or restore the individual's physiological function.

Microtia repair is considered Reconstructive although no Functional Impairment may be documented.

Not medically necessary (Cosmetic)

Cosmetic Procedures

Cosmetic criteria: Procedures that change or improve appearance without significantly improving physiological function are considered Cosmetic and are generally not covered.

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.

InterQual-based coverage

Tissue transfer and jaw reconstruction

InterQual reference: Flap repair (Tissue Transfer) and specified jaw reconstruction procedures (e.g., bone augmentation of maxilla/mandible, TMJ reconstruction, relevant osteotomies) are considered reconstructive and medically necessary in certain circumstances when InterQual CP criteria are met; refer to the InterQual CP: Procedures for detailed clinical coverage criteria.

UnitedHealthcare uses InterQual for primary medical/surgical criteria; consult the InterQual criteria for the specific clinical coverage elements required for prior authorization and medical necessity determinations.

Coverage guidance (interpretive)

Policy distinguishes reconstructive (potentially covered when medically necessary) from cosmetic procedures (not covered when solely for appearance).

Coverage determination guidance: Reconstructive procedures address physiological abnormalities from injury, illness, developmental abnormality, or congenital anomaly to improve or restore physiologic function; cosmetic procedures are performed to reshape or enhance appearance without improving physiological function.

Apply federal, state, or contractual plan requirements when determining coverage; in applicable cases, use InterQual criteria for primary medical/surgical decision support and prior authorization requirements.

Procedures that are explicitly identified in this policy as Cosmetic are excluded from coverage because they do not improve a functional, physical, or physiological impairment. Examples in the policy list codes and services that are categorized as cosmetic and therefore generally not medically necessary when the sole purpose is appearance enhancement.

When a procedure does not improve or restore physiologic function but instead changes or improves appearance, it is characterized as Cosmetic and is generally not covered. Reconstructive procedures, by contrast, are intended to address a physical or physiological abnormality from injury, illness, developmental abnormality, or congenital anomaly and to improve or restore physiologic function; if those reconstructive criteria are not met, the intervention is treated as cosmetic.

The policy lists specific procedure codes that are considered cosmetic examples, including but not limited to dermabrasion and related abrasion/chemical peel codes (e.g., 15780–15783, 15786–15789, 15792–15793), rhytidectomy and related face/neck codes (e.g., 15824–15829), subcutaneous filling material injections (e.g., 11950–11954), suction-assisted lipectomy of head/neck (15876), otoplasty for protruding ear (69300), ear piercing (69090), and injection of deoxycholic acid (J0591). These codes are identified in the Applicable Codes section as procedures that do not improve a Functional, Physical, or physiological Impairment and are considered Cosmetic.

Interventions performed solely to reshape or enhance appearance without a demonstrated physiologic benefit are considered not medically necessary under this policy. Psychological or social consequences alone do not convert a cosmetic procedure into a reconstructive one; coverage requires documentation that the procedure is likely to significantly improve or restore physiologic function.

Applicable Codes and Code Groups

Covered CPT/HCPCS Codes (reference list start)CPT

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

Codes that may be Cosmetic; review requiredCPT

11922	Tattooing; 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 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 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 to 30.0 sq cm
14060	Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less
14061	Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 to 30.0 sq cm

1–10 of 13

1/2

Tissue transfer / grafting codes (may be cosmetic or reconstructive)CPT

15572	Formation of direct or tubed pedicle; scalp, arms, or legs
15574	Formation of direct or tubed pedicle; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, or feet
15730	Midface flap with preservation of vascular pedicle(s)
15731	Forehead flap with preservation of vascular pedicle
15733	Muscle/myocutaneous/fasciocutaneous flap; head and neck with named vascular pedicle
15734	Muscle/myocutaneous/fasciocutaneous flap; trunk
15736	Muscle/myocutaneous/fasciocutaneous flap; upper extremity
15738	Muscle/myocutaneous/fasciocutaneous flap; lower extremity
15740	Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel
15756	Free muscle or myocutaneous flap with microvascular anastomosis

1–10 of 13

1/2

Additional reconstructive/cosmetic mixed codesCPT

15773	Grafting of autologous fat to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less
15774	Grafting of autologous fat; each additional 25 cc injectate
17999	Unlisted procedure, skin, mucous membrane, and subcutaneous tissue
19316	Mastopexy
19325	Breast augmentation with implant
21137	Reduction forehead; contouring only
21138	Reduction forehead; contouring and application of prosthetic material or bone graft
21139	Reduction forehead; contouring and setback of anterior frontal sinus wall

Craniofacial reconstruction codesCPT

21172	Reconstruction superior-lateral orbital rim and lower forehead, advancement, or alteration, with or without grafts
21175	Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement, or alteration
21179	Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic)
21180	Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft
21181	Reconstruction by contouring of benign tumor of cranial bones (e.g., fibrous dysplasia)
21182	Reconstruction of orbital walls/rims/forehead after excision of benign tumor; total area bone grafting < 40 sq cm
21183	Reconstruction of orbital walls/rims/forehead after excision of benign tumor; total area bone grafting 40-80 sq cm
21184	Reconstruction of orbital walls/rims/forehead after excision of benign tumor; total area bone grafting > 80 sq cm
21208	Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)
21209	Osteoplasty, facial bones; reduction

Maxillofacial/jaw/orbital codesCPT

21230	Graft; rib cartilage, autogenous, to face, chin, nose, or ear
21235	Graft; ear cartilage, autogenous, to nose or ear
21248	Reconstruction of mandible or maxilla, endosteal implant; partial
21249	Reconstruction of mandible or maxilla, endosteal implant; complete
21255	Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage
21256	Reconstruction of orbit with osteotomies and with bone grafts
21260	Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach
21261	Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and extracranial approach

Cosmetic procedure codes (considered cosmetic per policy)CPTNot Covered

11950	Subcutaneous injection of filling material (e.g., 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 filling material; over 10.0 cc
15775	Punch graft 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)

Additional Cosmetic codesmixedNot Covered

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

Added Applicable CPT CodesCPT

15832
15833
15834
15835
15836
15837
15838
15839
15876

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

InterQual-based prior authorization

Prior authorization/coverage for Tissue Transfer (Flap) and other specified reconstructive procedures is based on InterQual® CP criteria. Providers must use the InterQual criteria referenced in this policy when requesting authorization.

InterQual® is the primary medical/surgical criteria used by UnitedHealthcare for these procedures.
If InterQual® does not contain applicable criteria, UnitedHealthcare may use its Medical Policies, Coverage Determination Guidelines, or Utilization Review Guidelines as appropriate.

Prior Authorization

Updated applicable CPT codes — prior authorization may be required

Prior authorization may be required for newly added or updated CPT codes related to reconstructive, flap, or jaw reconstruction procedures. Providers should verify prior authorization requirements through UnitedHealthcare's standard prior authorization processes before scheduling or performing services.

Providers must follow UnitedHealthcare prior authorization submission processes and include InterQual criteria references when applicable.
Check payer portals or contact UnitedHealthcare Provider Services for the list of CPT codes requiring prior authorization.

Denial Risk

Cosmetic procedures denial risk

Cosmetic procedures are generally not covered and may be denied when they do not meet reconstructive criteria. Ensure documentation demonstrates physiologic function improvement to avoid denial.

Procedures that change or improve appearance without significantly improving physiological function are considered Cosmetic and are typically not covered.
Correction of an anatomical congenital anomaly that does not improve or restore physiologic function is considered Cosmetic and may be denied.

Note

Follow plan-specific requirements

Coverage determinations must follow the applicable federal, state, and contractual benefit plan requirements. In the event of a conflict between this policy and those requirements, the federal, state, or contractual requirements govern.

Verify plan-specific benefits, exclusions, and any state Medicaid requirements prior to authorization or claim submission.
Kentucky-specific rules or department requirements may supersede standard UnitedHealthcare policy where applicable.

Documentation Required

Medical necessity documentation

Documentation must show a physical and/or physiological abnormality that is causing a Functional Impairment and that the proposed treatment is likely to significantly improve or restore physiological function. Include objective findings and functional limitations.

Provide clinical notes, imaging, prior treatment history, and objective measures of functional impairment.
Note: Microtia repair is considered Reconstructive even if documented functional impairment is not present — include supporting clinical rationale.

Note

Check applicable plan and regulatory requirements

Providers must check federal, state, and contractual coverage requirements which may differ from this Medical Policy. This policy is informational and does not replace plan-specific contract language.

Before relying on this policy, confirm any applicable regulatory or plan mandates that affect coverage.
In case of conflict, federal, state, or contractual requirements for benefit plan coverage govern.

Note

FDA informational note

FDA approval status is informational only and is not a basis for coverage decisions. Many surgical procedures are not subject to FDA approval, though devices used may be; check FDA device listings when relevant.

FDA approval (or lack thereof) does not alone determine coverage.
Refer to FDA device databases for information on specific instruments or implants used in procedures.

Definitions — Key Terms

Reconstructive Procedures — Definition entry for reconstructive procedures.

DefinitionA procedure is considered Reconstructive and medically necessary when: (1) documentation shows the physical and/or physiological abnormality is causing a Functional Impairment that requires correction; and (2) the proposed treatment is of proven efficacy and is likely to significantly improve or restore the individual's physiological function.

Primary resultThe primary result of reconstructive surgery is not a changed or improved physical appearance; it is related to injury, sickness, or a congenital anomaly and aims to restore physiologic function.

InterQual noteCertain tissue transfer (flap) and jaw reconstruction procedures are considered reconstructive and medically necessary in circumstances when InterQual CP criteria are met.

Cosmetic Procedures — Definition entry for cosmetic procedures.

DefinitionCosmetic Surgery is performed to reshape normal structures of the body to enhance an individual's appearance and self‑esteem; procedures that change or improve appearance without significantly improving physiological function are considered Cosmetic and are generally not covered.

Coverage stanceProcedures performed solely to reshape or enhance appearance without improving physiological function are characterized as cosmetic and are not reconstructive.

Exclusion rationaleProcedures correcting congenital anatomy without restoring physiologic function are considered cosmetic; psychological or social consequences alone do not make a procedure reconstructive.

Functional or Physical Impairment — Definition entry for functional impairment used in coverage decisions.

DefinitionA Functional or Physical Impairment is a deviation from normal function of a tissue or organ that results in significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities or basic life functions.

Exhibit areasFunctional impairment is exhibited by difficulties in physical and motor tasks, independent movement, or performing basic life functions.

Role in coverageDocumentation that a physical/physiological abnormality is causing a Functional Impairment is required to meet reconstructive medical necessity criteria (except for specified exceptions such as Microtia repair).

Microtia — Definition noting microtia treated as reconstructive even without documented functional impairment.

DefinitionMicrotia is a congenital condition characterized by an underdeveloped and abnormally shaped external ear; internal ear structures are generally unaffected.

Policy treatmentMicrotia repair is considered Reconstructive under this policy even when no Functional Impairment is documented.

Severity spectrumThere are four types of Microtia ranging from a smaller but normally shaped ear (type I) to anotia, the absence of external ear structures (most severe).

Reconstructive vs Cosmetic Procedures — Additional definition / comparison entries.

Reconstructive vs Cosmetic — core distinctionReconstructive procedures address physical/physiological abnormalities (injury, illness, developmental abnormality, congenital anomaly) to improve or restore physiologic function; Cosmetic procedures are performed to reshape or enhance appearance without improving physiological function.

Coverage implicationReconstructive procedures may be medically necessary and covered when criteria are met; Cosmetic procedures are generally not covered when performed solely for appearance.

Documentation requirementFor reconstructive coverage, documentation must show the abnormality is causing a Functional Impairment and the proposed treatment is likely to restore physiological function (see Microtia exception).

Microtia (updated) — Updated Microtia definition (revision noted in policy changes).

Updated Microtia definitionDefinition of 'Microtia' was updated in the policy on 05/01/2026; Microtia remains defined as a congenital condition of an underdeveloped and abnormally shaped external ear and is treated as reconstructive under this policy.

Policy change note05/01/2026 Summary of Changes: Updated definition of 'Microtia' and added CPT codes 15832–15839 and 15876 to Applicable Codes.

Practical effectMicrotia repair continues to be considered reconstructive even when no functional impairment is documented; providers should reference the updated definition when submitting documentation or prior authorization requests.

OpenPayer

Cosmetic and Reconstructive Procedures (for Kentucky Only)

Coverage Criteria — Reconstructive vs Cosmetic

Applicable Codes and Code Groups

Provider Requirements, Prior Authorization, and Documentation

Background and Scope

Definitions — Key Terms

Policy Revision History