Procedures That Are Considered Cosmetic
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Defines procedures, services, and codes that University Health Alliance (UHA) considers cosmetic and not covered, with limited exceptions for asterisked codes that may be medically necessary with prior authorization. Applies to UHA members and providers submitting claims to UHA.
No material clinical or coverage changes in this revision.
Coverage Criteria — Cosmetic vs Reconstructive
inv-01: General exclusion — cosmetic
Covered only when reconstructive intent restores or materially improves physical function or when exception applies:
Includes services provided for psychological or psychiatric reasons; complications from prior cosmetic services are excluded.
inv-02: Congenital anomaly — conditional coverage
Reconstructive surgery for congenital abnormalities:
If severe impairment exists, reconstructive surgery may be considered medically necessary.
inv-03: Not medically necessary / Cosmetic — Listed procedures are considered cosmetic
Listed procedures are considered cosmetic
The list is illustrative and subject to change; providers should check UHA for the most current list.
UHA does not cover certain procedures that are considered cosmetic. Common exclusions include breast reduction surgery; breast reconstruction and/or implants (except following mastectomy for cancer); excision of superficial benign tumors of the skin and subcutaneous tissue (for example, skin tags and lipomas); and the diagnosis and treatment of complications from prior cosmetic or reconstructive services. These exclusions apply when the service is primarily intended to improve appearance and does not restore or materially improve physical function, including services provided for psychological or psychiatric reasons.
The enumerated procedure codes in this document are provided for reference only and are not intended to be an all-inclusive list of procedures considered cosmetic. The list is subject to change without prior notice. Providers should check the UHA website or contact UHA at the phone numbers listed in the policy to verify the most current list before submitting claims or scheduling services.
Procedures that are performed primarily to improve appearance, or that are provided for psychological or psychiatric reasons, are considered not medically necessary and are not covered by UHA. This exclusion specifically applies when the service does not restore or materially improve a physical function.
Items included on the following list are considered cosmetic by UHA and are therefore not medically necessary. Claims for procedures on this list are subject to noncoverage unless a specific exception (e.g., an asterisked code with prior authorization) applies.
Procedure Codes — Cosmetic / Not Covered
| 11200 | Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions. |
| 11201 | Removal of skin tags, multiple fibrocutaneous tags, any area; each additional ten lesions. |
| 11920 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less. |
| 11921 | Micropigmentation; 6.0 sq cm or less. |
| 11922 | Micropigmentation; 6.1 to 20.0 sq cm. |
| 11950 | Subcutaneous injection of "filling" material (e.g., collagen); 1 cc or less. |
| 11951 | Subcutaneous injection of "filling" material (e.g., collagen); 1.1 to 5.0 cc. |
| 11952 | Subcutaneous injection of "filling" material (e.g., collagen); 5.1 to 10.0 cc. |
| 11954 | Subcutaneous injection of "filling" material (e.g., collagen); over 10.0 cc. |
| 15770 | Graft; derma-fat-fascia. |
| 15780 | Dermabrasion; total face (e.g., for acne scarring, fine wrinkling, rhytids, general keratosis). |
| 15781 | Dermabrasion; segmental, face. |
| 15782 | Dermabrasion; regional, other than face. |
| 15783 | Dermabrasion; superficial, any site, (e.g., tattoo removal). |
| 15786 | Abrasion; single lesion (e.g., keratosis, scar). |
| 15787 | Abrasion; each additional four lesions or less. |
| 15788 | Chemical peel, facial; epidermal. |
| 15789 | Chemical peel, facial; dermal. |
| 15792 | Chemical peel, nonfacial; epidermal. |
| 15793 | Chemical peel, nonfacial; dermal. |
| 15824 | Rhytidectomy; forehead. |
| 15825 | Rhytidectomy; neck with platysmal tightening (platysmal flap, "P-flap"). |
| 15826 | Rhytidectomy; glabellar frown lines. |
| 15828 | Rhytidectomy; cheek, chin, and neck. |
| 15829 | Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap. |
| 15830 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy. |
| 15832 | Excision, excessive skin and subcutaneous tissue (including lipectomy); thigh. |
| 15833 | Excision, excessive skin and subcutaneous tissue (including lipectomy); leg. |
| 15834 | Excision, excessive skin and subcutaneous tissue (including lipectomy); hip. |
| 15835 | Excision, excessive skin and subcutaneous tissue (including lipectomy); buttock. |
| 15876 | Suction assisted lipectomy; head and neck. |
| 15877 | Suction assisted lipectomy; trunk. |
| 15878 | Suction assisted lipectomy; upper extremity. |
| 15879 | Suction assisted lipectomy; lower extremity. |
| 17106 | Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); less than 10 sq cm. |
| 17107 | Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); 10.0 - 50.0 sq cm. |
| 17108 | Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); over 50.0 sq cm. |
| 17340 | Cryotherapy (CO2 slush, liquid N2) for acne. |
| 17360 | Chemical Exfoliation for acne (e.g., acne paste, acid). |
| 17380 | Chemical Exfoliation for acne (e.g., acne paste, acid). |
| 19300 | Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma. |
| 19316 | Mastectomy for gynecomastia. |
| 19318 | Mastopexy. |
| 19324 | Reduction mammaplasty. |
| 19325 | Mammaplasty, augmentation; without prosthetic implant. |
| 19328 | Mammaplasty, augmentation; with prosthetic implant. |
| 19330 | Removal if intact mammary implant. |
| 19340 | Removal of mammary implant material. |
| 19342 | Immediate insertion of breast prosthesis following mastopexy. |
| 19350 | Delayed insertion of breast prosthesis following mastopexy. |
| 21120 | Cartilage graft; nasal septum. |
| 21083 | Impression and custom preparation; palatal lift prosthesis. |
| 21087 | Impression and custom preparation; nasal prosthesis. |
| 21121 | Genioplasty; augmentation (autograft, allograft, prosthetic material). |
| 21122 | Genioplasty; sliding osteotomy, single piece. |
| 21125 | Augmentation, mandibular body or angle; prosthetic material. |
| 21127 | Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft). |
| 21137 | Reduction forehead; contouring only. |
| 21138 | Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft). |
| 21139 | Reduction forehead; contouring and setback of anterior frontal sinus wall. |
| 21141 | Reconstruction midface, LeFort I; single piece, segment movement in any direction, without bone graft. |
| 21142 | Reconstruction midface, LeFort I; two pieces, segment movement in any direction, without bone graft. |
| 21143 | Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, without bone graft. |
| 21145 | Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts). |
| 21146 | Reconstruction midface, LeFort I; two pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts). |
| 21147 | Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts). |
| 21150 | Reconstruction midface, LeFort II; anterior intrusion (e.g., Treacher-Collins Syndrome). |
| 21151 | Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts). |
| 21154 | Reconstruction midface, LeFort III (extra cranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I. |
| 21155 | Reconstruction midface, LeFort III (extra cranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I. |
| 21183 | Reconstruction of orbital walls, rims, forehead, nasoethmoid complex; bone grafting (various area sizes) / related reconstructions |
| 21184 | Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) |
| 21188 | Reconstruction midface, osteotomies and bone grafts; larger area bone grafting |
| 21193 | Reconstruction of mandibular rami, horizontal, vertical, 'C', or 'L' osteotomy; without bone graft |
| 21194 | Reconstruction of mandibular rami... with bone graft (includes obtaining graft) |
| 21195 | Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation |
| 21196 | Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation |
| 21198 | Osteotomy, mandible, segmental |
| 21199 | Osteotomy, mandible, segmental; with genioglossus advancement |
| 21206 | Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard) |
Provider Actions — Prior Authorization, Documentation, and Denial Risk
Verify coverage with UHA
The document is a reference of procedures considered cosmetic; providers must verify current coverage/policy with UHA prior to scheduling or claim submission.
- Contact UHA for current coverage: 808-532-4006 (Oahu) or 1-800-458-4600, extension 300 (neighbor islands).
Documentation and verification
Providers should check the UHA website or call UHA for the most current list; items marked with an asterisk on the list require prior authorization.
- Website: uhahealth.com
- Phone: 808-532-4006 or 1-800-458-4600, extension 300
Check current list before submission
Before submitting claims, providers must confirm the current list of cosmetic procedures with UHA via the website or the phone numbers listed, since the list is subject to change without prior notice.
- Use UHA website (uhahealth.com) or call 808-532-4006 / 1-800-458-4600 ext. 300 to confirm code status before claim submission.
Denial for cosmetic intent
Procedures primarily intended to improve appearance or that do not restore or materially improve a physical function are not covered and may be denied.
- This exclusion also applies to services provided for psychological or psychiatric reasons.
Denial risk for cosmetic procedures
Procedures listed in this document are considered cosmetic and therefore subject to noncoverage; claims for listed procedures risk denial.
- The list is illustrative and not exhaustive; listed CPT codes are examples of procedures that may be denied as cosmetic.
Inventory placeholder — no specific provider action text was provided in the source for this item but is retained for mapping.
Inventory placeholder — no specific provider action text was provided in the source for this item but is retained for mapping.
Definitions — Cosmetic and Reconstructive
Background
This policy distinguishes cosmetic procedures—services primarily intended to improve appearance but that do not restore or materially improve physical function—from reconstructive procedures, which are intended to restore function or correct impairment. Reconstructive surgery for congenital abnormalities may be covered only when the anomaly severely impairs or impedes normal, essential bodily functions.
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