ModifiedWellcare HawaiiPolicy MC.CP.MP.31

Cosmetic and Reconstructive Procedures

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Medical-necessity criteria for cosmetic and reconstructive surgery for Medicare health plans, supplementing specified Medicare LCD criteria. Reconstructive procedures may be covered when functional criteria are met; cosmetic surgery performed solely to improve appearance is excluded.

Policy Summary

PayerWellcare Hawaii

PolicyCosmetic and Reconstructive Procedures

Policy CodePolicy N/A

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionDocument failure of conservative therapy before reconstructive surgery unless it is not standard of care or is contraindicated.

SourceLink

POLICY UPDATE CHANGES

Five CPT codes for reconstructive penile procedures were added to the policy.

The policy removed the prior criteria items I.A.1 through I.A.3 and combined the policy criteria sections.

The policy description was revised to clarify that the applicable LCDs do not provide sufficient criteria to consistently determine medical necessity in all clinically appropriate scenarios.

The policy was revised during the 08/26 annual review by combining sections I and A and removing criteria I.A.1 through I.A.3.

Five CPT codes—54163, 54360, 54380, 54385, and 54390—were added to the policy during the 08/26 annual review.

Criteria I.A.4 regarding procedures that may be covered when improving appearance is the only benefit was removed during the 08/25 annual review.

The policy description was updated to state that applicable LCDs do not provide sufficient criteria to consistently determine medical necessity in all clinically appropriate scenarios.

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ModifiedWellcare HawaiiPolicy MC.CP.MP.31

Cosmetic and Reconstructive Procedures

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Policy Summary

PayerWellcare Hawaii

PolicyCosmetic and Reconstructive Procedures

Policy CodePolicy N/A

Change TypeModified

Effective DateN/A

Next Review DateN/A

Key ActionDocument failure of conservative therapy before reconstructive surgery unless it is not standard of care or is contraindicated.

SourceLink

POLICY UPDATE CHANGES

Five CPT codes for reconstructive penile procedures were added to the policy.

The policy removed the prior criteria items I.A.1 through I.A.3 and combined the policy criteria sections.

The policy description was revised to clarify that the applicable LCDs do not provide sufficient criteria to consistently determine medical necessity in all clinically appropriate scenarios.

The policy was revised during the 08/26 annual review by combining sections I and A and removing criteria I.A.1 through I.A.3.

Five CPT codes—54163, 54360, 54380, 54385, and 54390—were added to the policy during the 08/26 annual review.

Criteria I.A.4 regarding procedures that may be covered when improving appearance is the only benefit was removed during the 08/25 annual review.

The policy description was updated to state that applicable LCDs do not provide sufficient criteria to consistently determine medical necessity in all clinically appropriate scenarios.

Medical Necessity and Coverage Positions

Reconstructive surgery medical necessity

Covered when all applicable elements are met:

Procedure indication
- The procedure is performed to improve the function of an abnormal body part caused by illness, trauma, or a congenital defect.
At least one therapy condition
- Conservative therapy has failed.
- Conservative therapy is not standard of care for the condition.
- Conservative therapy is contraindicated.

Cosmetic surgery solely to improve appearance

Not medically necessary and not a covered benefit:

Cosmetic-only surgery

The surgery is performed for the sole purpose of improving appearance or reshaping normal structures to improve appearance and self-esteem.

For Medicare health plans affiliated with Centene Corporation, cosmetic surgery performed for the sole purpose of improving appearance is considered not medically necessary and is not a covered benefit.

Surgery that reshapes normal body structures to improve appearance and self-esteem is generally considered not medically necessary.

Codes Supporting Coverage Criteria

Covered CPT CodesCPTCovered

11200	Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions
11402	Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter 1.1 to 2.0 cm
11403	Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter 2.1 to 3.0 cm
11404	Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter 3.1 to 4.0 cm
11406	Excision, benign lesion including margins, except skin tag, trunk, arms or legs; excised diameter over 4.0 cm
11420	Excision, benign lesion including margins, except skin tag, scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less
11421	Excision, benign lesion including margins, except skin tag, scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm
11422	Excision, benign lesion including margins, except skin tag, scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm
11423	Excision, benign lesion including margins, except skin tag, scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm
11424	Excision, benign lesion including margins, except skin tag, scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm

1–10 of 100

1/10

Covered HCPCS CodesHCPCSCovered

G0429	Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome as a result of highly active antiretroviral therapy
Q2026	Injection, Radiesse, 0.1 ml
Q2028	Injection, Sculptra, 0.5 mg

CPT Codes Added to PolicyCPT

54163
54360
54380
54385
54390

Documentation and Coverage Review Requirements

Documentation Required

Document Conservative-Therapy Failure

Document failure of conservative therapy before recommending reconstructive surgery to improve the function of an abnormal body part caused by illness, trauma, or congenital defect. The prerequisite does not apply when conservative therapy is not the standard of care for the condition or is contraindicated.

Billing Rule

Review Governing Coverage Requirements

Before applying this policy, review all applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles. For Medicaid members/enrollees, state Medicaid coverage provisions take precedence when they conflict with this policy; consult the applicable state Medicaid manual.

Policy Context

Reconstructive surgery addresses abnormal body structures resulting from congenital defects, developmental abnormalities, previous or concurrent surgeries, trauma, infection, tumors, or disease. It is generally performed to improve the function of the affected body part and may or may not restore a normal appearance.

Key Terms

Reconstructive surgery

DefinitionSurgery performed on abnormal body structures caused by congenital defects, developmental abnormalities, previous or concurrent surgeries, trauma, infection, tumors, or disease.

Primary purposeGenerally performed to improve the functioning of a body part.

AppearanceMay or may not restore a normal appearance.

Functional impairment

DefinitionA health condition in which the normal function of a body part or organ system is less than age-appropriate full capacity.

ExamplesDecreased range of motion, diminished eyesight, or diminished hearing.