ModifiedUnitedHealthcarePolicy CSNC.MP.007.09

Cosmetic and Reconstructive Procedures (for North Carolina Only)

Defines applicability, coding guidance, and references for cosmetic and reconstructive surgical procedures for UnitedHealthcare in North Carolina; directs providers to North Carolina Medicaid clinical coverage criteria for medical necessity determinations.

Policy Summary

PayerUnitedHealthcare

PolicyCosmetic and Reconstructive Procedures (for North Carolina Only)

Policy CodePolicy CSNC.MP.007.09

Change TypeAdded CPT codesclarified state fee-schedule exclusion

Effective DateNov 1, 2025

Next Review Date

Key ActionRefer to North Carolina Medicaid Clinical Coverage Policy 1-O-1 and InterQual for prior authorization and medical necessity determinations.

SourceLink

POLICY UPDATE CHANGES

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

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

Noted that CPT code 15876 is not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program

Archived previous policy version CSNC.MP.007.08.

>=100CPT/HCPCS codes listed

9CPT codes added

1State-specific (NC only)

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Coverage and Medical Necessity Criteria

Medical Necessity Reference

Covered when ALL of the following are met:

Referenced criteria: Medical necessity for reconstructive procedures and flap repair shall be determined by North Carolina Medicaid Clinical Coverage Policy 1-O-1 (Reconstructive and Cosmetic Surgery) and InterQual CP: Procedures, Tissue Transfer (Flap).

Providers must consult those referenced sources for the detailed clinical indications, required documentation, and AND/OR logic used to establish medical necessity.

A subset of procedure codes included in this policy are explicitly identified as considered cosmetic. These codes are described in the Applicable Codes list and are characterized as services that do not improve a functional, physical, or physiological impairment and are therefore considered cosmetic when performed for cosmetic indications. Examples from the list include dermabrasion and chemical peel codes (e.g., 15780–15783, 15788–15793), subcutaneous injection of filling material codes (11950–11954), and several rhytidectomy and aesthetic procedure codes (e.g., 15824–15829).

The policy notes that codes marked with an asterisk (*) in the Applicable Codes list are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program. Specifically, during the 11/01/2025 update, CPT code 15876 was added to the Applicable Codes list and the policy was clarified to indicate that 15876 is not on the North Carolina Medicaid Fee Schedule and therefore may not be covered for NC Medicaid members. Providers should account for this state-specific exclusion when submitting claims or requesting prior authorization.

The document’s Applicable Codes section enumerates the procedures that the policy treats as considered cosmetic. These include, but are not limited to: subcutaneous filling material injections (CPT 11950–11954), punch graft hair transplant codes (15775–15776), dermabrasion and abrasion codes (15780–15787), chemical peel codes (15788–15793), multiple rhytidectomy (facelift) codes (15824–15829), electrolysis (17380), otoplasty and ear piercing codes (69090, 69300), select injectable and implant codes (J0591, L8600, L8607, Q2026, Q2028), and other aesthetic procedure codes listed in the Applicable Codes section. These codes are identified because they do not correct a functional, physical, or physiological impairment and therefore are categorized as cosmetic services in this policy.

Applicable Codes and Coding Guidance

Applicable CPT/HCPCS Codes (may be cosmetic or reconstructive as noted)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 104

1/11

State Fee Schedule Notationmixed

*	Codes labeled with an asterisk (*) are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program.

Applicable CPT Codes (added)CPT

15832
15833
15834
15835
15836
15837
15838
15839
15876	Not on the State of North Carolina Medicaid Fee Schedule (may not be covered by NC Medicaid)

Adjacent tissue transfer defect size thresholds

Defect threshold — small (10.0 sq cm)Adjacent tissue transfer codes specify 'defect 10 sq cm or less' for multiple sites (e.g., 14000, 14020, 14040, 14060).

Defect threshold — medium (10.1 to 30.0 sq cm)Adjacent tissue transfer codes specify 'defect 10.1 sq cm to 30.0 sq cm' for multiple sites (e.g., 14001, 14021, 14041, 14061).

Defect threshold — large (30.1 to 60.0 sq cm)Adjacent tissue transfer code 14301 specifies 'defect 30.1 sq cm to 60.0 sq cm'.

Provider Requirements, Prior Authorization, and Billing Notes

Prior Authorization

Prior Authorization per NC Medicaid / InterQual

Prior Authorization required per North Carolina Medicaid and InterQual clinical criteria. Refer to the North Carolina Medicaid Clinical Coverage Policy 1-O-1 (Reconstructive and Cosmetic Surgery) and InterQual CP: Procedures, Tissue Transfer (Flap) for medical necessity criteria prior to scheduling flap repair procedures.

Prior authorization requirements and medical necessity determinations follow NC Medicaid and InterQual criteria.
Providers should obtain authorization when required by the member's plan or state program prior to procedure.

Billing Rule

Applicable CPT Code Additions and Coverage Note

The listed CPT codes are provided for reference and do not guarantee coverage or payment. Inclusion of a code in this policy does not imply the service is a covered benefit under the member's specific plan.

Clinical Background and Scope

Tissue transfer (flap) repair refers to surgical transfer of tissue (a flap) for reconstruction of defects. Within this policy framework, flap (tissue transfer) repair is identified as a reconstructive procedure that may be considered medically necessary when clinical indications meet established medical necessity criteria. Medical necessity determinations for flap repair are not defined in detail here; providers must refer to the North Carolina Medicaid Clinical Coverage Policy (1‑O‑1) and InterQual CP: Procedures, Tissue Transfer (Flap) for the specific clinical criteria, documentation requirements, and prior authorization processes that govern when flap procedures are covered.

Key Terms and Policy Definitions

Tissue Transfer (Flap) Repair — definition and clinical note

DefinitionTissue Transfer (Flap) Repair — surgical transfer of tissue (flap) used for reconstruction; flap repair is considered reconstructive and medically necessary in certain circumstances.

Clinical guidanceFor medical necessity clinical coverage criteria, providers must refer to InterQual CP: Procedures, Tissue Transfer (Flap).

Documentation noteDetermination of reconstructive necessity requires meeting the clinical criteria specified by InterQual; consult that source for indication-specific requirements.

Medical Policy — UnitedHealthcare designation and use

DesignationUnitedHealthcare Medical Policy — provides assistance in interpreting UnitedHealthcare standard benefit plans and is informational; does not constitute medical advice.

Policy Changes and Version History

2025-11-01code_additionLatest

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

2025-11-01coverage_clarification

Noted that CPT code 15876 is not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program.