Cosmetic and Reconstructive Surgery Reimbursement
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Governs reimbursement and coverage criteria for reconstructive and cosmetic surgery and related services for University Health Alliance members, including prior authorization requirements and exclusions.
No material clinical or coverage changes in this revision.
Coverage Criteria and Exclusions
Coverage Criteria and Exclusions
Reconstructive procedures are covered when they restore or correct impaired bodily function or specific conditions; cosmetic services and related complications are excluded.
ALL of the following
ANY of the following
- Any bodily function that was lost, impaired, or damaged as a result of an illness or injury.
- Gender-specific services that are medically necessary for members with gender dysphoria who are undergoing gender reassignment surgery (see UHA's Gender Identity Services policy for guidelines and limitations).
- Developmental abnormalities present from birth that severely impair or impede normal, essential bodily functions.
- Reconstruction of the breast on which a mastectomy was performed and surgery for reconstruction of the other breast to produce a symmetrical appearance (including prostheses).
- Post-traumatic, infectious, or congenital anomalies (for example, post-burn scarring or post-ablative surgery) which affect appearance—particularly facial appearance—to such an extent that social integration would be impossible or difficult; these will be considered for coverage on an individual basis when they meet the statutory definition of 'necessity.'
Prior Authorization and Provider Requirements
Obtain Prior Authorization for Procedures that May Be Cosmetic
If the planned procedure or service could reasonably be considered cosmetic, obtain prior authorization from UHA before proceeding. Submit the prior authorization request through UHA's online portal; if you do not yet have a portal login, contact UHA at 808-532-4000 to establish one.
- Prior authorization must be obtained when a procedure could be considered cosmetic.
- Submit requests via UHA's online portal; call 808-532-4000 to establish a login if needed.
Key Definitions
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