ModifiedUnitedHealthcarePolicy CS027NJ.V

Cosmetic and Reconstructive Procedures (for New Jersey Only)

Defines UnitedHealthcare New Jersey coverage stance and criteria for distinguishing reconstructive (medically necessary) versus cosmetic procedures and lists applicable procedure codes for review.

Policy Summary

PayerUnitedHealthcare

PolicyCosmetic and Reconstructive Procedures (for New Jersey Only)

Policy CodePolicy CS027NJ.V

Change TypeDefinition updates and added CPT codes

Effective DateNov 1, 2025

Next Review Date

Key ActionVerify plan and New Jersey Medicaid coverage and obtain prior authorization when required for newly added CPT codes before providing service.

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-specificpolicy applies only to

microtia exceptionmicrotia exception

many CPT codescodes listed

some codesNJ Medicaid exceptions

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Coverage Criteria

Reconstructive Procedures (Medical Necessity Criteria)

A procedure is 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; 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.

Procedures that change or improve appearance without significantly improving physiological function are generally not covered under this policy as cosmetic. A procedure is considered Cosmetic when it does not meet the Reconstructive criteria (see Reconstructive Procedures). Correction of an anatomical congenital anomaly that does not improve or restore physiologic function is generally considered cosmetic, and documentation of psychological or social impact alone does not make the procedure reconstructive.

CPT codes 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, and 15876 were added to the Applicable Codes list in the November 1, 2025 policy revision. A notation was also added that these CPT codes are not on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered by the State of New Jersey Medicaid Program; providers should verify New Jersey Medicaid and other plan coverage prior to service.

The policy identifies specific procedure codes as commonly cosmetic (examples include subcutaneous filler injection codes such as 11950–11954, injectable products listed as Q2026/Q2028, dermabrasion and chemical peel codes 15780–15789, and rhytidectomy and liposuction–type codes listed in the Applicable Codes section). Codes designated as Cosmetic do not improve functional, physical, or physiological function and are considered not medically necessary under this policy unless documentation demonstrates they meet the reconstructive criteria.

Applicable Procedure Codes

Listed procedure codes (may be cosmetic or reconstructive)CPT|HCPCS|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... 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 102

1/11

State Medicaid exceptionsmixed

* (asterisk note)

Codes labeled with an asterisk are not on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered by the State of New Jersey Medicaid Program.

Applicable CPT Codes addedCPT

15832	CPT code added (description as listed in Applicable Codes)
15833	CPT code added (description as listed in Applicable Codes)
15834	CPT code added (description as listed in Applicable Codes)
15835	CPT code added (description as listed in Applicable Codes)
15836	CPT code added (description as listed in Applicable Codes)
15837	CPT code added (description as listed in Applicable Codes)
15838	CPT code added (description as listed in Applicable Codes)
15839	CPT code added (description as listed in Applicable Codes)
15876	CPT code added (description as listed in Applicable Codes)

Graft/Injectate volume thresholds — selected CPTs (15771–15774)

Code 15771Grafting of autologous fat to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate.

Code 15772Each additional 50 cc injectate, or part thereof (adds to 15771).

Code 15773Grafting of autologous fat to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate.

Code 15774Each additional 25 cc injectate, or part thereof (adds to 15773).

Provider Actions and Requirements

Prior Authorization

Code review / Prior authorization

Some procedure codes listed in the Applicable Codes section may be cosmetic rather than reconstructive. Providers must review coding and clinical documentation to determine whether a procedure meets the Reconstructive criteria in this policy before billing or claiming coverage. Prior authorization may be required by the plan or applicable state program.

Affected codes: see Applicable Codes list; codes marked with an asterisk (*) are not on the NJ Medicaid Fee Schedule and may not be covered by NJ Medicaid.
Prior authorization: implied — verify plan-specific prior authorization requirements before scheduling or performing services.

Denial Risk

Cosmetic procedures exclusion

Procedures that do not meet the Reconstructive criteria in this policy are considered Cosmetic and are generally not covered. Correction of an anatomical congenital anomaly that does not improve or restore physiologic function is typically Cosmetic. Psychological or social consequences alone do not convert a Cosmetic procedure into a Reconstructive one.

Background

Reconstructive procedures are intended to correct physical or physiological abnormalities that arise from injury, illness, developmental anomalies, or congenital conditions with the goal of improving or restoring physiologic function. Under this policy, a procedure is considered Reconstructive and medically necessary when ALL of the following are met: documentation that the physical and/or physiological abnormality is causing a Functional Impairment that requires correction, and that the proposed treatment is of proven efficacy and is likely to significantly improve or restore physiological function. Note: repair of microtia is considered reconstructive even if a Functional Impairment is not documented.

Definitions

Cosmetic Surgery

DefinitionSurgery performed solely for the purpose of beautifying an individual and which has no significant redeeming medical necessity (N.J.A.C. 10:54-5.3).

Coverage implicationProcedures deemed cosmetic that do not meet reconstructive criteria are generally not covered and may be denied.

Reference noteRefer to state and contractual requirements for applicable definitions and coverage determinations.

Functional or Physical Impairment

DefinitionA deviation from the normal function of a tissue or organ resulting in significantly limited capacity to perform physical activities or basic life functions (e.g., physical and motor tasks, independent movement, performing basic life functions).

Documentation requirement

Revision History

2025-11-01material_revisionLatest

Updated definition of 'Microtia'; added CPT codes 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, and 15876 to Applicable Codes and noted these codes are not on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered by NJ Medicaid; References section updated and previous policy version archived.

Policy Summary

PayerUnitedHealthcare

PolicyCosmetic and Reconstructive Procedures (for New Jersey Only)

Policy CodePolicy CS027NJ.V

Change TypeDefinition updates and added CPT codes

Effective DateNov 1, 2025

Next Review Date

Key ActionVerify plan and New Jersey Medicaid coverage and obtain prior authorization when required for newly added CPT codes before providing service.

SourceLink

On This Page

Examples: dermabrasion (15780–15783), chemical peels (15788–15793), many filler and implant injection codes listed as Cosmetic.
Microtia note: microtia repair is considered reconstructive in this policy even if Functional Impairment is not documented.

Denial Risk

Governance may trigger denial

Coverage determinations must follow applicable federal, state, and contractual benefit plan requirements. If there is a conflict between this policy and those governing documents, the federal, state, or contractual requirements control and may result in denial of coverage.

State-specific rules: codes flagged as not on the New Jersey Medicaid Fee Schedule may not be covered by NJ Medicaid.
Providers must check the member’s plan documents and any applicable state mandates prior to providing services.

Note

Reference plan terms

When deciding coverage for a specific member, providers must reference the member’s federal, state, and contractual plan terms because those terms govern coverage and may differ from this policy. This policy is informational and does not replace plan-specific benefit determinations.

Verify plan and state Medicaid coverage before performing services, especially for newly added CPT codes listed in Applicable Codes.
UnitedHealthcare may use third‑party tools (e.g., InterQual) to assist in benefit administration; those tools may impose additional clinical criteria.

Medical necessity documentation must show the impairment is causing functional limitation that requires correction and that proposed treatment is likely to improve physiological function.

ApplicabilityUsed to distinguish reconstructive (medically necessary) procedures from cosmetic procedures under this policy.

Microtia

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

Coverage stanceMicrotia repair is considered reconstructive under this policy even when functional impairment is not documented.

Policy updateDefinition of 'Microtia' was updated in the policy effective 11/01/2025.

Reconstructive Surgery

DefinitionRepair or reconstruction of changes due to trauma, infection, or surgery whose need for correction demonstrates a significant medical necessity (N.J.A.C. 10:54-5.3).

CriteriaA procedure is reconstructive and medically necessary when documentation shows (1) the abnormality causes a Functional Impairment requiring correction, and (2) the proposed treatment is of proven efficacy and likely to significantly improve or restore physiological function.

Microtia exceptionMicrotia repair is considered reconstructive even if functional impairment is not documented.

Microtia (policy definition update)

Updated definitionMicrotia: definition updated in the policy; see Applicable Codes/Definitions section for details.

Effective dateUpdate effective 11/01/2025 as noted in Policy History/Revision Information.

Coverage noteMicrotia repair remains classified as reconstructive under this policy even when a functional impairment is not documented.