ModifiedUnitedHealthcarePolicy CS027TN.AA

Cosmetic and Reconstructive Procedures (for Tennessee Only)

Policy governing coverage determinations for cosmetic and reconstructive surgical procedures for Tennessee Medicaid and CoverKids enrollees; describes medical necessity criteria, definitions, and applicable codes.

Policy Summary

PayerUnitedHealthcare

PolicyCosmetic and Reconstructive Procedures (for Tennessee Only)

Policy CodePolicy CS027TN.AA

Change TypeDefinitions revised9 CPT codes added

Effective DateNov 1, 2025

Next Review Date

Key ActionVerify applicable plan, state or federal requirements and any third‑party tool (e.g., InterQual) requirements and obtain prior authorization if required before performing procedures.

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.

Tennessee Medicaid & CoverKidsplans this policy applies to

Tennessee-onlygeographic applicability

9CPT codes added

Reconstructivemicrotia classification

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Coverage Criteria for Reconstructive and Cosmetic Procedures

Reconstructive Procedures (General)

Covered (Reconstructive and Medically Necessary) when ALL of the following are met:

Reconstructive medical necessity: 1) Documentation that 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 deemed likely to significantly improve or restore the individual's physiological function.

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

Per this policy, cosmetic procedures are excluded in accordance with TennCare Medicaid Chapter 1200-13-13-.10. Cosmetic services are those that are intended to change or improve appearance and do not improve physiological function. Providers must refer to the TennCare exclusion rule when determining whether a procedure is considered cosmetic for Tennessee Medicaid and CoverKids enrollees.

This policy references TennCare Medicaid Chapter 1200-13-13-.10 for exclusions related to cosmetic procedures. When state, federal, or contractual requirements differ from UnitedHealthcare’s cosmetic/reconstructive distinctions (for example, states that require coverage for repair of external congenital anomalies even without documented Functional Impairment), those governing requirements take precedence and must be followed.

The policy identifies specific procedure codes that are considered cosmetic because they do not improve a Functional, Physical, or physiological Impairment. Examples listed include injections and surface procedures such as 11950, 11951, 11952, 11954 (subcutaneous filling material injections), 15775, 15776 (punch grafts for hair transplant), and dermabrasion/abrasion codes 15780, 15781, 15782, 15783, 15786, 15787. These codes are classified as cosmetic (not medically necessary) under this policy unless state/federal/contractual rules require otherwise.

Applicable Procedure and Supply Codes

Applicable CPT/HCPCS codes (may be cosmetic; review required)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

Codes considered cosmetic (do not improve a Functional, Physical, or physiological Impairment)mixedNot 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.

Applicable CPT codes addedCPT

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

inv-08: graft area thresholds

Bone grafting total area — < 40 sq cmCode 21182: Reconstruction of orbital walls, rims, forehead, nasoethmoid complex...; total area of bone grafting less than 40 sq cm.

Bone grafting total area — > 40 sq cm but < 80 sq cmCode 21183: Reconstruction of orbital walls, rims, forehead, nasoethmoid complex...; total area of bone grafting greater than 40 sq cm but less than 80 sq cm.

Bone grafting total area — > 80 sq cmCode 21184: Reconstruction of orbital walls, rims, forehead, nasoethmoid complex...; total area of bone grafting greater than 80 sq cm.

inv-09: adjacent tissue defect size

Defect size — ≤ 10.0 sq cmCodes 14000, 14020, 14040, 14060: Adjacent tissue transfer or rearrangement for various sites; defect 10 sq cm or less.

Provider Requirements and Operational Notes

Prior Authorization

InterQual requirement and code review — Tissue transfer (flap) repairs

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). Click here to view the InterQual® criteria.

InterQual criteria should be reviewed to determine medical necessity for tissue transfer (flap) repairs.

Documentation Required

Medical necessity documentation

Documentation must demonstrate that a physical and/or physiological abnormality is causing a Functional Impairment that requires correction and that the proposed treatment is of proven efficacy and likely to significantly improve or restore physiological function. Note: Microtia repair is considered reconstructive even if a Functional Impairment cannot be documented.

Ensure medical records clearly describe the Functional or Physical Impairment and how the requested procedure will address it.

Definitions and Terminology

inv-19: Functional or Physical Impairment

DefinitionA Functional or Physical or physiological Impairment causes deviation from the normal function of a tissue or organ, resulting in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities; exhibited by difficulties in physical/motor tasks, independent movement, or performing basic life functions.

inv-20: Medically Necessary

Tennessee statutory definition'Medically Necessary' is defined by Tennessee Code Annotated, Section 71-5-144 and applies to TennCare enrollees; services must satisfy the statutory criteria and the TennCare medical necessity rule (chapter 1200-13-16).

ImplementationImplementation of the term is provided in the TennCare rules consistent with statutory provisions; enrollees are not entitled to services that fail to satisfy all criteria.

ScopeThe TennCare medical necessity rule controls in case of ambiguity between statutory and regulatory definitions.

Background

Reconstructive procedures are intended to correct or improve a physical or physiological abnormality resulting from injury, illness, developmental abnormality, or congenital condition. Coverage is determined when documentation shows the abnormality is causing a Functional Impairment and the proposed treatment is proven and likely to significantly improve or restore physiological function. The policy distinguishes reconstructive care from cosmetic procedures by focusing on restoration of function rather than appearance; for Tennessee enrollees, microtia repair is explicitly considered reconstructive under this policy even if a Functional Impairment is not documented.

Policy Summary

PayerUnitedHealthcare

PolicyCosmetic and Reconstructive Procedures (for Tennessee Only)

Policy CodePolicy CS027TN.AA

Change TypeDefinitions revised9 CPT codes added

Effective DateNov 1, 2025

Next Review Date

Key ActionVerify applicable plan, state or federal requirements and any third‑party tool (e.g., InterQual) requirements and obtain prior authorization if required before performing procedures.

SourceLink

On This Page

Defect size — 10.1–30.0 sq cmCodes 14001, 14021, 14041, 14061: Adjacent tissue transfer or rearrangement for various sites; defect 10.1 sq cm to 30.0 sq cm.

Defect size — 30.1–60.0 sq cmCode 14301: Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm.

Additional incrementsCode 14302: Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (list separately).

If applicable, reference definitions of Functional or Physical Impairment and Reconstructive Surgery.

Include clinical rationale tying symptoms/findings to functional limitation.

Billing Rule

Code listing is not coverage guarantee

Listing of a code in this policy is provided for reference only and does not imply the service is covered or eligible for reimbursement. Benefit coverage is determined by federal, state, and contractual requirements and applicable laws.

Codes listed in the Applicable Codes section are not a guarantee of coverage or payment.
Providers must not assume coverage solely because a code appears in this policy.

Prior Authorization

Verify prior authorization and plan requirements

Verify applicable prior authorization, plan, state or federal requirements and any third‑party tool requirements (for example, InterQual) before performing services. UnitedHealthcare may use third‑party tools to assist in administering benefits; providers should confirm any plan‑specific submission or PA processes.

Check member-specific benefit plan documents and state/federal mandates that may affect coverage.
Obtain and document prior authorization when required by the member's plan.
Confirm any third‑party criteria (e.g., InterQual) that may be applied to determine medical necessity prior to scheduling.

Note

Conflicts with plan/federal/state requirements

In the event of a conflict between this policy and federal, state, or contractual requirements for plan coverage, the federal, state, or contractual requirements govern. Providers should follow the controlling law or contract terms.

When state or federal mandates require coverage not reflected in this policy, follow the mandate.
Document any plan-specific exceptions or authorizations consistent with controlling requirements.

Documentation Required

Device and plan documentation

Document devices and instruments used during the procedure, and note that FDA approval of devices is informational only and not a basis for coverage. Verify device requirements and any plan/state/federal constraints.

List devices and instruments used and include FDA identifiers where applicable.
FDA approval does not imply coverage; check plan and regulatory requirements.

inv-21: Microtia

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

Severity rangeRanges from Type I (least severe: smaller ear with normal shape) to anotia (most severe: absence of external ear structures).

Clinical noteWhile Microtia affects appearance, it typically does not affect internal ear structures; repair is considered reconstructive under this policy context.

inv-22: Reconstructive Surgery

DefinitionReconstructive Surgery: surgery or other procedures related to an injury, sickness, or congenital anomaly where the primary result is improvement or restoration of physiologic function rather than changed appearance.

PurposePrimary objective is to improve or restore physiologic function, not solely cosmetic appearance.

ApplicationUsed for conditions from injury, illness, developmental abnormalities, or congenital anomalies when physiologic function can be improved or restored.

inv-23: Microtia

Updated definition effective 11/01/2025Policy History: 11/01/2025 Summary of Changes includes 'Updated definition of 'Microtia'.'

Related changesThe 11/01/2025 summary also added multiple CPT codes to Applicable Codes (e.g., 15832–15839, 15876).

Version noteThis update is part of a material change; providers should reference the revised Microtia definition in the 11/01/2025 policy version.