CurrentUnitedHealthcarePolicy CS027NE.T

Cosmetic and Reconstructive Procedures (for Nebraska Only)

Policy governs coverage determination for cosmetic and reconstructive surgical procedures for UnitedHealthcare members in Nebraska and instructs providers to reference state and contractual requirements and InterQual criteria where applicable.

Policy Summary

PayerUnitedHealthcare

PolicyCosmetic and Reconstructive Procedures (for Nebraska Only)

Policy CodePolicy CS027NE.T

Change TypeAdded codesreference updates

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and reference InterQual Tissue Transfer (Flap) criteria when submitting flap repair requests.

SourceLink

POLICY UPDATE CHANGES

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.

~120+Codes listed

NebraskaState-specific

InterQualExternal criteria

11/01/2025Effective

Coverage Criteria

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Reconstructive Procedures - Medical Necessity

Covered when procedure is reconstructive (not cosmetic) per state/contractual definitions and InterQual where referenced.

Reconstructive criteria: Procedure relates to an injury, sickness, developmental abnormality, or congenital anomaly and primarily aims to improve or restore physiologic function rather than change appearance

Refer to Nebraska DHHS, applicable federal/state/contractual requirements, and InterQual CP: Procedures, Tissue Transfer (Flap) for specific clinical criteria (e.g., flap/tissue transfer)

Cosmetic Procedures - Not Medically Necessary

Not covered when solely cosmetic.

Cosmetic procedures: Procedures or listed codes described as cosmetic that do not improve a functional, physical, or physiological impairment are considered cosmetic and not medically necessary when performed solely to improve appearance

See Applicable Codes list for examples of codes designated as cosmetic (e.g., injection fillers, many dermabrasion/chemical peel codes, certain rhytidectomy codes, otoplasty, malar augmentation)

The policy designates certain procedure codes as cosmetic when the service is performed solely to improve appearance and does not improve a functional, physical, or physiological impairment. When a listed code is identified as cosmetic, it is considered not medically necessary for coverage purposes if no functional indication exists. Coverage determinations for borderline services should reference applicable federal, state, or contractual requirements and any referenced clinical criteria (for example, InterQual) to determine whether a procedure is reconstructive (medically necessary) versus cosmetic (not medically necessary).

Examples of codes and procedures the policy identifies as considered cosmetic include injection fillers (CPT 11950–11954), dermabrasion and abrasion procedures (e.g., CPT 15780–15783, 15786–15788, 15792–15793), many rhytidectomy (facelift) codes (e.g., CPT 15824–15829), otoplasty (CPT 69300), malar augmentation with prosthetic material (CPT 21270), suction-assisted lipectomy of head and neck (CPT 15876), and related listed codes such as punch grafting for hair transplant and elective ear procedures. Injectable product HCPCS/CPT examples referenced include Q2026, Q2028 and other listed injectable supply codes.

Coding and Code Lists

May be cosmetic; review requiredCPT

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... each additional 20.0 sq cm
11960	Insertion of tissue expander(s) for other than breast, including subsequent expansion

Applicable Codes (may be cosmetic; review required)mixed

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
14301	Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm
15756	Free muscle or myocutaneous flap with microvascular anastomosis
15771	Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate
15772	Grafting of autologous fat ... each additional 50 cc injectate
15773	Grafting of autologous fat ... to face...; 25 cc or less injectate

1–10 of 32

1/4

Considered cosmetic (codes do not improve functional impairment)mixed

11950	Subcutaneous injection of filling material; 1 cc or less (considered cosmetic)
11951	Subcutaneous injection of filling material; 1.1 to 5.0 cc (considered cosmetic)
11952	Subcutaneous injection of filling material; 5.1 to 10.0 cc (considered cosmetic)
11954	Subcutaneous injection of filling material; over 10.0 cc (considered cosmetic)
15792	Chemical peel, nonfacial; epidermal (considered cosmetic)
15793	Chemical peel, nonfacial; dermal (considered cosmetic)
21270	Malar augmentation, prosthetic material (considered cosmetic)
69300	Otoplasty, protruding ear, with or without size reduction (considered cosmetic)

Injectables / suppliesHCPCS

Q2026	Injection, Radiesse, 0.1 ml
Q2028	Injection, sculptra, 0.5 mg
L8607	Injectable bulking agent for vocal cord medialization, 0.1 ml

Defect area thresholds in adjacent tissue transfer codes

Defect area ≤ 10.0 sq cmUse adjacent tissue transfer codes when the defect area is 10 sq cm or less (e.g., 14000, 14020, 14040, 14060)

Defect area 10.1–30.0 sq cmUse adjacent tissue transfer codes when the defect area is between 10.1 and 30.0 sq cm (e.g., 14001, 14021, 14041)

Defect area 30.1–60.0 sq cmUse adjacent tissue transfer codes when the defect area is between 30.1 and 60.0 sq cm (e.g., 14301)

Additional area incrementsFor defects larger than base code ranges, report additional area codes where specified (e.g., 14302 each additional 30.0 sq cm or part thereof)

Fat grafting injectate thresholds

Face injectate incrementsFat grafting to the face and related anatomic sites: 25 cc or less per primary code (e.g., 15773); report additional 25 cc increments with add-on code (e.g., 15774)

Trunk/extremities injectate incrementsFat grafting to trunk, breasts, scalp, arms, and/or legs: 50 cc or less per primary code (e.g., 15771); report additional 50 cc increments with add-on code (e.g., 15772)

Report separately when exceeding incrementsWhen injectate exceeds the primary code volume, report the corresponding each-additional injectate code as listed (per code descriptors)

Provider Actions & Authorization

Prior Authorization

InterQual criteria for Flap Repair

Flap repair is subject to InterQual clinical review. Prior authorization/clinical review may be required and providers should reference the InterQual CP: Procedures, Tissue Transfer (Flap) when requesting coverage determinations.

InterQual criteria apply for medical necessity determinations for Flap Repair
Prior authorization/clinical review may be required based on InterQual guidance

Note

Coverage contingent on contract/state/federal rules

Listing of a procedure or diagnosis code in this policy does not imply coverage. Benefit coverage is determined by applicable federal, state, or contractual requirements and laws. Providers must verify member benefits and any plan-specific rules before delivery of services.

Inclusion of a code in this policy is for reference only and is not a guarantee of coverage or payment
Benefit coverage is governed by federal, state, and contractual requirements which may require or limit coverage

Documentation Required

Document state/contractual justification

When submitting requests for coverage or prior authorization, providers must document the specific federal, state, or contractual basis for coverage (if applicable) and include clinical rationale that demonstrates how the request meets InterQual criteria and plan requirements.

Document the applicable federal, state, or contractual requirement if it affects coverage determination
Include complete clinical rationale and supporting documentation showing how InterQual criteria are met

Note

(Provider note)

Providers should review the InterQual criteria link and related policy instructions before submitting authorization requests. Related policies may apply for specific procedures or states; check state-specific notes where indicated.

Review InterQual CP: Procedures, Tissue Transfer (Flap) prior to request
Check related policies and state-specific guidance (e.g., Nebraska-specific policies) that may affect coverage

OpenPayer

Cosmetic and Reconstructive Procedures (for Nebraska Only)

Coverage Criteria

Coding and Code Lists

Provider Actions & Authorization

Definitions

Background