Cosmetic and Reconstructive Procedures (for Tennessee Only)
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Defines medical necessity and coverage approach for cosmetic versus reconstructive surgical procedures for TennCare Medicaid and CoverKids members in Tennessee.
Cosmetic Procedures: Updated instruction to refer to the Tennessee Department of Finance and Administration, Bureau of TennCare § 1200-13-13-.10: TennCare Medicaid, Exclusions for coverage criteria for cosmetic procedures.
Medical Records Documentation Used for Reviews: Added language clarifying that medical records documentation may be required to assess whether the member meets clinical criteria and that documentation must fully support medical necessity.
Definitions: Updated definitions of Functional Impairment and Reconstructive Procedures.
Related Policies: Added reference link to the Medical Policy titled Outpatient Surgical Procedures - Site of Service (for Tennessee Only).
Supporting Information: Updated References section to reflect current information and added CDC and ASPS sources.
Coverage Criteria
Medically Necessary Reconstructive Procedures
A procedure is considered reconstructive and Medically Necessary when ALL of the following are met:
Microtia exception explicitly allowed
Cosmetic Procedures (coverage stance)
Cosmetic procedures are excluded from medical necessity coverage except where federal, state, or contractual requirements mandate otherwise.
Policy defers to TennCare rules for cosmetic exclusions
Tissue Transfer (Flap) Repair
Tissue transfer (flap) repair is considered reconstructive and may be Medically Necessary when clinical criteria are met.
External InterQual criteria govern specifics
Coverage determination logic
Coverage and medical necessity determinations must follow this policy's clinical criteria and any applicable federal, state, or contractual requirements; documentation must support medical necessity.
Specific clinical criteria and procedure-level rules are in other sections or external tools (e.g., InterQual) referenced by this policy.
Cosmetic procedure exclusions for TennCare members are determined by the state’s TennCare rules. For coverage criteria related to cosmetic procedures, refer to the Tennessee Department of Finance and Administration, Bureau of TennCare § 1200-13-13-.10: TennCare Medicaid, Exclusions. UnitedHealthcare’s policy defers to those TennCare exclusions when applying cosmetic procedure coverage guidance for Tennessee Medicaid and CoverKids members.
Coverage determinations must follow both this clinical policy and any applicable federal, state, or contractual requirements. Some services that UnitedHealthcare may consider cosmetic could nonetheless be required to be covered under federal, state, or contractual law; providers should verify the governing benefit terms (for example, TennCare rules) before concluding a service is noncovered.
The policy identifies a set of CPT/HCPCS codes that are considered cosmetic because the procedures do not improve a functional, physical, or physiological impairment. Examples include filler injection codes (e.g., 11950–11954), hair transplant punch grafts (15775–15776), dermabrasion and chemical peels (15780–15793), rhytidectomy codes (15824–15829), excision of excess skin codes and liposuction codes (15832–15839, 15876), otoplasty and related ear procedures (69090, 69300), and injection of deoxycholic acid (J0591). This list is informational and each code requires clinical review to determine whether the individual service is cosmetic or medically necessary in the member’s circumstance.
Medical records and supporting documentation must be provided to assess whether a requested service meets clinical criteria for coverage. Availability of records alone does not guarantee coverage; the patient's medical record must fully support the medical necessity for the requested services and include, as applicable, relevant history, physical examination findings, and results of pertinent diagnostic tests or procedures. Documentation should be legible, maintained in the record, and made available upon request.
Coding
| 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 |
| 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 |
| 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 sq cm to 30.0 sq cm |
| No codes listed |
Provider Actions and Requirements
Code listing is informational — inclusion does not guarantee coverage
The policy lists procedure and diagnosis codes for reference only; inclusion of a code does not imply the service is covered, guarantee reimbursement, or ensure claim payment — each service requires review against benefit rules and clinical criteria.
- Listing is for reference and may not be all inclusive
- Inclusion does not imply coverage or reimbursement
Verify federal/state/contract benefits and authorization sources
Before relying on this policy, verify the applicable federal, state, or contractual benefit requirements for the member; prior authorization processes and coverage determinations follow plan/contract rules and may use third-party tools (e.g., InterQual) to assist in administration.
- Check federal, state, and contractual benefit requirements for the member
- Confirm if prior authorization is required per plan/contract
Policy is informational — confirm governing benefit terms
UnitedHealthcare reserves the right to modify policies and this document is informational; providers should use their independent clinical judgment and confirm governing benefit terms before proceeding.
- Policy is informational and not medical advice
- Confirm governing benefit terms for coverage decisions
Follow governing federal/state/contract requirements when conflicts exist
When there is a conflict between this policy and federal, state, or contractual requirements, the federal/state/contractual requirements govern; check those requirements before using this policy for coverage decisions.
- In the event of conflict, federal/state/contractual requirements control
- Refer to specific state rules (e.g., TennCare) as applicable
Medical records must be provided for review
Make the patient’s medical record available upon request and ensure it contains legible documentation to support medical necessity, including relevant history, physical examination, and results of pertinent diagnostic tests or procedures.
- Include relevant medical history
- Include physical examination findings
- Include results of pertinent diagnostic tests/procedures
- Maintain legible documentation in the medical record
Required medical record documentation to support medical necessity
Documentation must fully support the medical necessity for the requested services; examples include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, all maintained in the patient’s record and made available upon request.
- Relevant medical history
- Physical examination findings
- Pertinent diagnostic test/procedure results
- Legible documentation maintained in the record
Insufficient documentation may lead to denial
Lack of documentation demonstrating medical necessity — such as missing history, exam findings, or diagnostic results — may lead to denial of the requested service.
- Missing or incomplete history, exam, or test results increases denial risk
- Medical records may be requested to assess whether clinical criteria are met
Provide complete medical records or risk denial
Failure to provide medical records that fully support the medical necessity of the requested services can result in denial because documentation is required to assess whether the member meets clinical coverage criteria.
- Documentation must fully support medical necessity to avoid denial
- Availability of records does not guarantee coverage
Services marked cosmetic may be covered per federal/state/contract rules
Some services UnitedHealthcare considers cosmetic may nevertheless be required to be covered by federal, state, or contractual requirements (for example, TennCare rules); providers must consult and follow those governing requirements when determining coverage.
- Refer to TennCare § 1200-13-13-.10 for cosmetic procedure exclusions/coverage
- When state/contract requirements require coverage, those rules govern
Definitions
Background
Reconstructive procedures are performed to correct physical or physiological abnormalities arising from injury, illness, developmental or congenital anomalies with the primary intent to restore or improve physiologic function rather than to improve appearance. A procedure is considered reconstructive and Medically Necessary when all of the following are met: there is documentation that the abnormality is causing a Functional Impairment that requires correction and the proposed treatment is of proven efficacy and likely to significantly improve or restore physiological function. Note: microtia repair is explicitly considered reconstructive even when a functional impairment is not documented.
Revision History
Related Policies: added reference link to the Medical Policy 'Outpatient Surgical Procedures - Site of Service (for Tennessee Only)'; Cosmetic Procedures: updated instruction to refer to TennCare § 1200-13-13-.10 for cosmetic exclusions; Medical Records Documentation: added requirements that documentation may be required to assess clinical criteria, must fully support medical necessity, and examples of required documentation; Definitions: updated definitions of Functional Impairment and Reconstructive Procedures; References: updated supporting information.
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