Cosmetic and Reconstructive Procedures – Commercial and Individual Exchange Medical Policy

Cosmetic and Reconstructive Procedures

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UnitedHealthcare Commercial and Individual Exchange Medical Policy

Effective 08/01/2024

UnitedHealthcare

Commercial and Individual Exchange

Medical

Policy

Cosmetic and Reconstructive Procedures

Policy Number: MP.007.28

Effective Date: August 1, 2024

 Instructions for Use

Table of Contents Page

Application ............................................................................. 1

Coverage Rationale .............................................................. 1

Definitions .............................................................................. 2

Medical Records Documentation Used for Reviews ............. 2

Applicable Codes .................................................................. 2

Description of Services ......................................................... 6

Benefit Considerations .......................................................... 6

U.S. Food and Drug Administration ...................................... 6

References ............................................................................ 7

Policy History/Revision Information ...................................... 7

Instructions for Use ............................................................... 7

Application

UnitedHealthcare Commercial

This Medical Policy applies to all UnitedHealthcare Commercial benefit plans.

UnitedHealthcare Individual Exchange

This Medical Policy applies to Individual Exchange benefit plans in all states except for Colorado.

Coverage Rationale

 See Benefit Considerations

Reconstructive Procedures

A procedure is considered reconstructive and medically necessary when all of the following criteria are met:

There is documentation that the physical abnormality and/or physiological abnormality is causing a Functional

Impairment that requires correction; and

The proposed treatment is of proven efficacy and is deemed likely to significantly improve or restore the individual’s

physiological function

Note: Microtia

repair is considered Reconstructive although no Functional Impairment may be documented.

Related Commercial/Individual Exchange Policies

• Breast Reconstruction

• Breast Reduction Surgery

• Brow Ptosis and Eyelid Repair

• Gender Dysphoria Treatment

• Liposuction for Lipedema

• Omnibus Codes

• Orthognathic (Jaw) Surgery

• Outpatient Surgical Procedures – Site of Service

• Panniculectomy and Body Contouring Procedures

• Pectus Deformity Repair

• Plagiocephaly and Craniosynostosis Treatment

• Rhinoplasty and Other Nasal Procedures

• Surgical and Ablative Procedures for Venous

Insufficiency and Varicose Veins

•

Treatment of Temporomandibular Joint Disorders

Community Plan Policy

•

Cosmetic and Reconstructive Procedures

Medicare Advantage Policy

• Cosmetic and Reconstructive Procedures

Cosmetic and Reconstructive Procedures

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UnitedHealthcare Commercial and Individual Exchange Medical Policy

Effective 08/01/2024

Tissue Transfer (Flap) Repair

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.

Cosmetic Procedures

Cosmetic procedures are procedures or services that change or improve appearance without significantly improving

physiological function. A procedure is considered to be a cosmetic procedure when it does not meet the reconstructive

criteria in the reconstructive procedures section above.

Procedures that correct an anatomical congenital anomaly without improving or restoring physiologic function are

considered cosmetic procedures. The fact that a covered person may suffer psychological consequences or socially

avoidant behavior as a result of an Injury, sickness or congenital anomaly does not classify surgery (or other procedures

done to relieve such consequences or behavior) as a reconstructive procedure.

Note: Refer to the Benefit Considerations

section for additional information on cosmetic services and exclusions.

Definitions

The following definitions may not apply to all plans. Refer to the member specific benefit plan document for applicable

definitions.

Cosmetic Surgery: Cosmetic Surgery is performed to reshape normal structures of the body in order to enhance an

individual’s appearance and self-esteem (Freeman, 2023).

Functional or Physical Impairment: A Functional or physical or physiological impairment causes deviation from the

normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move,

coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas:

physical and motor tasks; independent movement; performing basic life functions (Medicare, 2023).

Microtia: Microtia is a birth defect of a baby’s ear. Microtia happens when the external ear is small and not formed

properly. The defect can vary from being barely noticeable to being a major problem with how the ear forms. Usually,

Microtia affects how the baby’s ear looks, but the parts of the ear inside the head are not affected (CDC, 2023).

Reconstructive Surgery: Surgery or other procedures which are related to an injury, sickness, or Congenital Anomaly.

The primary result of the procedure is not a changed or improved physical appearance (COC, 2018).

Medical Records Documentation Used for Reviews

Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that

may require coverage for a specific service. Medical records documentation may be required to assess whether the

member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the

protocol titled Medical Records Documentation Used for Reviews

Applicable Codes

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all

inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered

health service. Benefit coverage for health services is determined by the member specific benefit plan document and

applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to

reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.

Cosmetic and Reconstructive Procedures

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UnitedHealthcare Commercial and Individual Exchange Medical Policy

Effective 08/01/2024

CPT/HCPCS

Code

Description

The following codes may be cosmetic; review is required to determine if considered cosmetic or

reconstructive.

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 (List separately in addition

to code for primary procedure)

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

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

14301

Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm

14302

Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof

(List separately in addition to code for primary procedure)

15570

Formation of direct or tubed pedicle, with or without transfer; trunk

15572

Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legs

15574

Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck,

axillae, genitalia, hands or feet

15730

Midface flap (i.e., zygomaticofacial flap) with preservation of vascular pedicle(s)

15731

Forehead flap with preservation of vascular pedicle (e.g., axial pattern flap, paramedian forehead

flap)

15733

Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (i.e.,

buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae)

15734

Muscle, myocutaneous, or fasciocutaneous flap; trunk

15736

Muscle, myocutaneous, or fasciocutaneous flap; upper extremity

15738

Muscle, myocutaneous, or fasciocutaneous flap; lower extremity

15740

Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel

15756

Free muscle or myocutaneous flap with microvascular anastomosis

15769

Grafting of autologous soft tissue, other, harvested by direct excision (e.g., fat, dermis, fascia)

15771

Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or

legs; 50 cc or less injectate

Note: Refer to the Medical Policy titled Breast Reconstruction.

15772

Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or

legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary

procedure)

Note: Refer to the Medical Policy titled Breast Reconstruction.

15773

Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears,

orbits, genitalia, hands, and/or feet; 25 cc or less injectate

Cosmetic and Reconstructive Procedures

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UnitedHealthcare Commercial and Individual Exchange Medical Policy

Effective 08/01/2024

CPT/HCPCS

Code

Description

The following codes may be cosmetic; review is required to determine if considered cosmetic or

reconstructive.

15774

Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears,

orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (List separately in

addition to code for primary procedure)

17999

Unlisted procedure, skin, mucous membrane and subcutaneous tissue

19316

Mastopexy

19325 Breast augmentation with implant

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

21172

Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or

without grafts (includes obtaining autografts)

21175

Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration

(e.g., plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining

autografts)

21179

Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or

prosthetic material)

21180

Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes

obtaining grafts)

21181

Reconstruction by contouring of benign tumor of cranial bones (e.g., fibrous dysplasia), extracranial

21182

Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and

extracranial excision of benign tumor of cranial bone (e.g., fibrous dysplasia), with multiple

autografts (includes obtaining grafts); total area of bone grafting less than 40 sq cm

21183

Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and

extracranial excision of benign tumor of cranial bone (e.g., fibrous dysplasia), with multiple

autografts (includes obtaining grafts); total area of bone grafting greater than 40 sq cm but less than

80 sq cm

21184

Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and

extracranial excision of benign tumor of cranial bone (e.g., fibrous dysplasia), with multiple

autografts (includes obtaining grafts); total area of bone grafting greater than 80 sq cm

21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)

21209 Osteoplasty, facial bones; reduction

21230 Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)

21235 Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)

21248 Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder); partial

21249 Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder); complete

21255

Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining

autografts)

21256

Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining

autografts) (e.g., micro-ophthalmia)

21260 Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach

21261

Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and extracranial

approach

21263

Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement

21267

Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach

21268

Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and

extracranial approach

Cosmetic and Reconstructive Procedures

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UnitedHealthcare Commercial and Individual Exchange Medical Policy

Effective 08/01/2024

CPT/HCPCS

Code

Description

The following codes may be cosmetic; review is required to determine if considered cosmetic or

reconstructive.

21275 Secondary revision of orbitocraniofacial reconstruction

21295

Reduction of masseter muscle and bone (e.g., for treatment of benign masseteric hypertrophy);

extraoral approach

21296

Reduction of masseter muscle and bone (e.g., for treatment of benign masseteric hypertrophy);

intraoral approach

21299

Unlisted craniofacial and maxillofacial procedure

28344

Reconstruction, toe(s); polydactyly

30540

Repair choanal atresia; intranasal

30545

Repair choanal atresia; transpalatine

30620

Septal or other intranasal dermatoplasty (does not include obtaining graft)

L8600

Implantable breast prosthesis, silicone or equal

L8607

Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary

supplies

Q2026

Injection, Radiesse, 0.1 ml

Q2028

Injection, sculptra, 0.5 mg

The following codes are considered cosmetic; the codes do not improve a functional, physical, or

physiological impairment.

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

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 (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 4 lesions or less (List separately in addition to code for primary

procedure)

15788

Chemical peel, facial; epidermal

15789

Chemical peel, facial; dermal

15792

Chemical peel, nonfacial; epidermal

15793

Chemical peel, nonfacial; dermal

15819

Cervicoplasty

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

17380

Electrolysis epilation, each 30 minutes

21270

Malar augmentation, prosthetic material

69090

Ear piercing

69300

Otoplasty, protruding ear, with or without size reduction

Cosmetic and Reconstructive Procedures

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UnitedHealthcare Commercial and Individual Exchange Medical Policy

Effective 08/01/2024

CPT/HCPCS

Code

Description

The following codes are considered cosmetic; the codes do not improve a functional, physical, or

physiological impairment.

J0591 Injection, deoxycholic acid, 1 mg

CPT

is a registered trademark of the American Medical Association

Description of Services

Reconstructive procedures treat a physical and/or physiological abnormality related to an injury, illness, development

abnormality, or congenital anomaly to improve or restore physiologic function. Whereas cosmetic procedures are

performed to reshape or enhance appearance without improving physiological function (ASPS, 2023).

Benefit Considerations

Some states require benefit coverage for services that UnitedHealthcare considers cosmetic procedures, such as repair of

external congenital anomalies in the absence of a Functional Impairment. Refer to the member specific benefit plan

document.

Cosmetic procedures are excluded from coverage.

In most benefit plans the following cosmetic procedures are specifically excluded from coverage:

Pharmacological regimens, nutritional procedures or treatments.

Scar or tattoo removal or revision procedures (such as salabrasion, chemosurgery and other such skin abrasion

procedures).

Skin abrasion procedures performed as a treatment for acne.

Liposuction or removal of fat deposits considered undesirable, including fat accumulation under the male breast and

nipple. This exclusion does not apply to reconstructive liposuction.

Treatment for skin wrinkles or any treatment to improve the appearance of the skin.

Treatment for spider veins.

Sclerotherapy treatment of veins.

Hair removal or replacement by any means, except for hair removal as part of genital reconstruction prescribed by a

physician for the treatment of gender dysphoria.(For laser or electrolysis hair removal in advance of genital

reconstruction, refer to the Medical Policy titled

Gender Dysphoria Treatment.

Additional Information

Benefits for reconstructive procedures include breast reconstruction following a mastectomy, and reconstruction of the

non-affected breast to achieve symmetry. Other services required by the Women's Health and Cancer Rights Act of

1998, including breast prostheses and treatment of complications, are provided in the same manner and at the same

level as those for any other covered health care service. Refer to the Medical Policy titled

Breast Reconstruction.

If the original service was not a covered benefit under the contract or UnitedHealthcare guidelines, (e.g. cosmetic,

investigational, not a covered health service, etc.), then benefits are limited to the treatment of the complication.

Examples include, but are not limited to:

o Removal of a leaking or defective silicone breast prosthesis is a covered health care service. However, benefits

for replacement of the breast prosthesis are only available if the original prosthesis was considered

"reconstructive."

U.S. Food and Drug Administration (FDA)

This section is to be used for informational purposes only. FDA approval alone is not a basis for coverage.

Many cosmetic and reconstructive interventions are surgical procedures and are not subject to FDA approval. However,

devices and instruments used during the procedures may require FDA approval. Refer to the following website for

additional information: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm

. (Accessed January 16, 2024)

Cosmetic and Reconstructive Procedures

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UnitedHealthcare Commercial and Individual Exchange Medical Policy

Effective 08/01/2024

References

American Medical Association (AMA). CPT

Assistant Online. Available at: https://www.ama-assn.org/practice-

management/cpt. Accessed January 16, 2024.

American Society of Plastic Surgeons. Cosmetic Procedures. Available at: https://www.plasticsurgery.org/cosmetic-

procedures. Accessed February 27, 2024.

American Society of Plastic Surgeons. Reconstructive Procedures. Available at:

https://www.plasticsurgery.org/reconstructive-procedures

. Accessed February 27, 2024.

Centers for Disease Control and Prevention. (2023, February 23). Facts about anotia/microtia. The Center for Disease

Control and Prevention. Available at: https://www.cdc.gov/ncbddd/birthdefects/anotia-microtia.html

. Accessed January 16,

2024.

Freeman, M. (2023). The differences between plastic surgery and cosmetic surgery and why board certification matters.

American Society of Plastic Surgeons. Available at:

https://www.plasticsurgery.org/news/articles/the-differences-between-

plastic-surgery-and-cosmetic-surgery-and-why-board-certification-matters. Accessed January 16, 2024.

Medicare Coverage Database. Local Coverage Determination. Sacroiliac Joint Injections and Procedures L39462. 2023.

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=39462

. Accessed January 16, 2024.

UnitedHealthcare Insurance Company Generic Certificate of Coverage 2018.

United Healthcare Insurance Company Individual Exchange Health Benefit Plan Generic Certificate of Coverage (COC)

2024.

Policy History/Revision Information

Date

Summary of Changes

09/01/2024

Related Policies

Updated reference link to the Medicare Advantage Medical Policy titled Cosmetic and

Reconstructive Procedures

08/01/2024

Related Policies

Added reference link to the:

o Medical Policy titled Outpatient Surgical Procedures – Site of Service

o Medicare Advantage Coverage Summary titled Cosmetic and Reconstructive Procedures

Medical Records Documentation Used for Reviews (previously titled Documentation

Requirements)

Replaced list of Required Clinical Information with instruction to refer to the protocol titled

Medical Records Documentation Used for Reviews

Definitions

Updated definition of “Reconstructive Surgery”

Applicable Codes

Revised list of CPT codes that may be cosmetic (review is required to determine if considered

cosmetic or reconstructive); removed 30560

Benefit Considerations

Added reference link to the Medical Policy titled Breast Reconstruction

Supporting Information

Updated Description of Services and References sections to reflect the most current information

Archived previous policy version MP.007.27

Instructions for Use

This Medical Policy provides assistance in interpreting UnitedHealthcare standard benefit plans. When deciding coverage,

the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may

differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs. Before using

this policy, please check the member specific benefit plan document and any applicable federal or state mandates.

UnitedHealthcare reserves the right to modify its Policies and Guidelines as necessary. This Medical Policy is provided for

informational purposes. It does not constitute medical advice.

Cosmetic and Reconstructive Procedures

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UnitedHealthcare Commercial and Individual Exchange Medical Policy

Effective 08/01/2024

This Medical Policy may also be applied to Medicare Advantage plans in certain instances. In the absence of a Medicare

National Coverage Determination (NCD), Local Coverage Determination (LCD), or other Medicare coverage guidance,

CMS allows a Medicare Advantage Organization (MAO) to create its own coverage determinations, using objective

evidence-based rationale relying on authoritative evidence (Medicare IOM Pub. No. 100-16, Ch. 4, §90.5

UnitedHealthcare may also use tools developed by third parties, such as the InterQual

criteria, to assist us in

administering health benefits. UnitedHealthcare Medical Policies are intended to be used in connection with the

independent professional medical judgment of a qualified health care provider and do not constitute the practice of

medicine or medical advice.