NC Medicaid Medicaid
Reconstructive and Cosmetic Surgery Clinical Coverage Policy No: 1-O-1
Amended Date: September 1, 2024
24H23 i
To all beneficiaries enrolled in a Prepaid Health Plan (PHP): for questions about benefits and
services available on or after implementation, please contact your PHP.
Table of Contents
1.0 Description of the Procedure, Product, or Service ........................................................................... 1
Reconstructive Surgery .................................................................................................................... 1
Cosmetic Surgery ............................................................................................................................. 1
2.0 Eligibility Requirements .................................................................................................................. 1
2.1 Provisions............................................................................................................................ 1
2.1.1 General ................................................................................................................... 1
2.1.2 Specific .................................................................................................................. 1
2.2 Special Provisions ............................................................................................................... 2
2.2.1 EPSDT Special Provision: Exception to Policy Limitations for a Medicaid
Beneficiary under 21 Years of Age ....................................................................... 2
3.0 When the Procedure, Product, or Service Is Covered ...................................................................... 3
3.1 General Criteria Covered .................................................................................................... 3
3.2 Specific Criteria Covered .................................................................................................... 3
3.2.1 Specific criteria covered by Medicaid ................................................................... 3
3.2.2 Medicaid Additional Criteria Covered ................................................................... 3
4.0 When the Procedure, Product, or Service Is Not Covered ............................................................... 3
4.1 General Criteria Not Covered ............................................................................................. 3
4.2 Specific Criteria Not Covered ............................................................................................. 4
4.2.1 Specific Criteria Not Covered by Medicaid ........................................................... 4
4.2.2 Medicaid Additional Criteria Not Covered ............................................................ 4
5.0 Requirements for and Limitations on Coverage .............................................................................. 4
5.1 Prior Approval .................................................................................................................... 4
5.2 Prior Approval Requirements ............................................................................................. 4
5.2.1 General ................................................................................................................... 4
5.2.2 Specific .................................................................................................................. 5
6.0 Provider(s) Eligible to Bill for the Procedure, Product, or Service ................................................. 5
6.1 Provider Qualifications and Occupational Licensing Entity Regulations ........................... 5
6.2 Provider Certifications ........................................................................................................ 5
7.0 Additional Requirements ................................................................................................................. 5
7.1 Compliance ......................................................................................................................... 5
8.0 Policy Implementation/Revision Information .................................................................................. 7
Attachment A: Claims-Related Information ................................................................................................. 9
A. Claim Type ......................................................................................................................... 9
B. International Classification of Diseases and Related Health Problems, Tenth Revisions,
C
linical Modification (ICD-10-CM) and Procedural Coding System (PCS) ..................... 9
NC Medicaid Medicaid
Reconstructive and Cosmetic Surgery Clinical Coverage Policy No: 1-O-1
Amended Date: September 1, 2024
24H23 ii
C.
Code(s) ................................................................................................................................ 9
D. Modifiers ............................................................................................................................. 9
E. Billing Units ........................................................................................................................ 9
F. Place of Service .................................................................................................................. 9
G. Co-payments ..................................................................................................................... 10
H. Reimbursement ................................................................................................................. 10
NC Medicaid Medicaid
Reconstructive and Cosmetic Surgery Clinical Coverage Policy No: 1-O-1
Amended Date: September 1, 2024
CPT codes, descriptors, and other data only are copyright 2023 American Medical Association.
All rights reserved. Applicable FARS/DFARS apply.
1
24H23
Related Clinical Coverage Policies
Refer to https://medicaid.ncdhhs.gov/ for the related coverage policies listed below:
1A-9, Blepharoplasty/Blepharoptosis (Eyelid Repair)
1A-12, Breast Surgeries
1A-15, Surgery for Clinically Severe or Morbid Obesity
1-O-2, Craniofacial Surgery
1-O-3, Keloid Excision and Scar Revision
1-O-5, Rhinoplasty and/or Septoplasty
4A, Dental Services
4B, Orthodontic Services
1.0 Description of the Procedure, Product, or Service
Reconstructive Surgery
Reconstructive surgery is performed to treat body parts affected aesthetically or functionally by
congenital defects, developmental abnormalities or trauma.
Cosmetic Surgery
Cosmetic plastic surgery includes surgical and nonsurgical procedures that enhance and reshape
structures of the body to improve appearance and confidence.
2.0 Eligibility Requirements
2.1 Provisions
2.1.1 General
(The term “General” found throughout this policy applies to all Medicaid
policies)
a. An eligible beneficiary shall be enrolled in the NC Medicaid Program
(Medicaid is NC Medicaid program, unless context clearly indicates
otherwise).
b. Provider(s) shall verify each Medicaid beneficiary’s eligibility each time a
service is rendered.
c. The Medicaid beneficiary may have service restrictions due to their
eligibility category that would make them ineligible for this service.
2.1.2 Specific
(The term “Specific” found throughout this policy only applies to this policy)
a. Medicaid
None Apply.
NC Medicaid Medicaid
Reconstructive and Cosmetic Surgery Clinical Coverage Policy No: 1-O-1
Amended Date: September 1, 2024
24H23 2
2.2 Special Provisions
2.2.1 EPSDT Special Provision: Exception to Policy Limitations for a
Medicaid Beneficiary under 21 Years of Age
a. 42 U.S.C. § 1396d(r) [1905(r) of the Social Security Act]
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a
federal Medicaid requirement that requires the state Medicaid agency to
cover services, products, or procedures for Medicaid beneficiary under 21
years of age if the service is medically necessary health care to correct or
ameliorate a defect, physical or mental illness, or a condition [health
problem] identified through a screening examination (includes any
evaluation by a physician or other licensed practitioner).
This means EPSDT covers most of the medical or remedial care a child
needs to improve or maintain his or her health in the best condition possible,
compensate for a health problem, prevent it from worsening, or prevent the
development of additional health problems.
Medically necessary services will be provided in the most economic mode,
as long as the treatment made available is similarly efficacious to the service
requested by the beneficiary’s physician, therapist, or other licensed
practitioner; the determination process does not delay the delivery of the
needed service; and the determination does not limit the beneficiary’s right to
a free choice of providers.
EPSDT does not require the state Medicaid agency to provide any service,
product or procedure:
1. that is unsafe, ineffective, or experimental or investigational.
2. that is not medical in nature or not generally recognized as an accepted
method of medical practice or treatment.
Service limitations on scope, amount, duration, frequency, location of
service, and other specific criteria described in clinical coverage policies may
be exceeded or may not apply as long as the provider’s documentation shows
that the requested service is medically necessary “to correct or ameliorate a
defect, physical or mental illness, or a condition” [health problem]; that is,
provider documentation shows how the service, product, or procedure meets
all EPSDT criteria, including to correct or improve or maintain the
beneficiary’s health in the best condition possible, compensate for a health
problem, prevent it from worsening, or prevent the development of additional
health problems.
b. EPSDT and Prior Approval Requirements
1. If the service, product, or procedure requires prior approval, the fact that
the beneficiary is under 21 years of age does NOT eliminate the
requirement for prior approval.
2. IMPORTANT ADDITIONAL INFORMATION about EPSDT and
prior approval is found in the NCTracks Provider Claims and Billing
Assistance Guide, and on the EPSDT provider page. The Web addresses
are specified below.
NC Medicaid Medicaid
Reconstructive and Cosmetic Surgery Clinical Coverage Policy No: 1-O-1
Amended Date: September 1, 2024
24H23 3
NCTracks Provider Claims and Billing Assistance Guide:
https://www.nctracks.nc.gov/content/public/providers/provider-
manuals.html
EPSDT provider page: https://medicaid.ncdhhs.gov/
3.0 When the Procedure, Product, or Service Is Covered
Note: Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for a
Medicaid Beneficiary under 21 Years of Age.
3.1 General Criteria Covered
Medicaid shall cover the procedure, product, or service related to this policy when
medically necessary, and:
a. the procedure, product, or service is individualized, specific, and consistent with
symptoms or confirmed diagnosis of the illness or injury under treatment, and not in
excess of the beneficiary’s needs;
b. the procedure, product, or service can be safely furnished, and no equally effective
and more conservative or less costly treatment is available statewide; and
c. the procedure, product, or service is furnished in a manner not primarily intended for
the convenience of the beneficiary, the beneficiary’s caretaker, or the provider.
3.2 Specific Criteria Covered
3.2.1 Specific criteria covered by Medicaid
Medicaid shall cover reconstructive and cosmetic surgery when the beneficiary
meets the following specific criteria:
a. improves or restores physical function;
b. corrects significant deformity resulting from disease, trauma, accidental
injury, or previous therapeutic process;
c. corrects congenital or developmental anomalies that have resulted in
significant functional impairment or disfigurement; or
d. corrects acquired deformities.
3.2.2 Medicaid Additional Criteria Covered
None Apply.
4.0 When the Procedure, Product, or Service Is Not Covered
Note: Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for a
Medicaid Beneficiary under 21 Years of Age.
4.1 General Criteria Not Covered
Medicaid shall not cover the procedure, product, or service related to this policy when:
a. the beneficiary does not meet the eligibility requirements listed in Section 2.0;
b. the beneficiary does not meet the criteria listed in Section 3.0;
c. the procedure, product, or service duplicates another provider’s procedure, product,
or service; or
d. the procedure, product, or service is experimental, investigational, or part of a clinical
trial.
NC Medicaid Medicaid
Reconstructive and Cosmetic Surgery Clinical Coverage Policy No: 1-O-1
Amended Date: September 1, 2024
24H23 4
4.2 Specific Criteria Not Covered
4.2.1 Specific Criteria Not Covered by Medicaid
Medicaid shall not cover the following:
a. Cosmetic Surgery
Cosmetic surgery, as defined in Section 1.0, is not covered. Psychiatric or
emotional distress is not considered a medical necessity indicator for
cosmetic procedures.
The following procedures are always considered to be cosmetic and therefore
are not covered:
1. augmentation of small breasts;
2. buttocks or thigh lifts;
3. diastasis recti repair;
4.
ear piercing;
5. hair removal of any method;
6. excision or correction of frown lines;
7. hair implants or transplants for alopecia;
8. laser skin resurfacing; and
9. psoralens ultraviolet A (PUVA) treatment for vitiligo.
b. Reconstructive Surgery
Reconstructive surgery or procedures are not covered in the absence of
documentation that the procedure will be performed primarily to
restore/improve function or to correct deformity resulting from congenital or
developmental anomaly, disease, trauma, or previous therapeutic process.
Excision of excessive skin and subcutaneous tissue (including lipectomy) are
always considered cosmetic when medical necessity for reconstructive
surgery is not met. If medical necessity is documented, prior approval may
be submitted as a reconstructive surgery request.
4.2.2 Medicaid Additional Criteria Not Covered
None Apply
5.0 Requirements for and Limitations on Coverage
Note: Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for
Medicaid beneficiaries under 21 Years of Age.
5.1 Prior Approval
Medicaid shall require prior approval for Reconstructive Cosmetic and Surgery. The
provider shall obtain prior approval before rendering Reconstructive Cosmetic and
Surgery.
5.2 Prior Approval Requirements
5.2.1 General
The provider(s) shall submit to the Department of Health and Human Services
(DHHS) Utilization Review Contractor the following:
a. the prior approval request; and
NC Medicaid Medicaid
Reconstructive and Cosmetic Surgery Clinical Coverage Policy No: 1-O-1
Amended Date: September 1, 2024
24H23 5
b. all health records and any other records that support the beneficiary has met
the specific criteria in Subsection 3.2 of this policy.
5.2.2 Specific
The following information must be submitted electronically by the rendering
provider via the NCTracks Provider Portal with the prior approval request to
determine medical necessity:
a. the location and cause of the defect;
b. medical reasons for the procedure;
c. pre-surgery medical photographs of the defect;
d. listing of the CPT codes describing the procedures to be performed;
e. documentation of pain, infection, and irritation; and
f. documentation of function that will be improved or restored.
Note: For Medicaid coverage criteria and prior approval requirements for dental,
breast, brow, craniofacial, bariatric, rhinoplasty, keloid and scar revision
procedures, refer to criteria in specific policies available at
https://medicaid.ncdhhs.gov/. Clinical Coverage Policy 1-O-1 does not apply to
these services.
6.0 Provider(s) Eligible to Bill for the Procedure, Product, or Service
To be eligible to bill for the procedure, product, or service related to this policy, the provider(s)
shall:
a. meet Medicaid qualifications for participation;
b. have a current and signed Department of Health and Human Services (DHHS) Provider
Administrative Participation Agreement; and
c. bill only for procedures, products, and services that are within the scope of their clinical
practice, as defined by the appropriate licensing entity.
6.1 Provider Qualifications and Occupational Licensing Entity Regulations
None Apply.
6.2 Provider Certifications
None Apply.
7.0 Additional Requirements
Note: Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for a
Medicaid Beneficiary under 21 Years of Age.
7.1 Compliance
Provider(s) shall comply with the following in effect at the time the service is rendered:
a. All applicable agreements, federal, state and local laws and regulations including the
Health Insurance Portability and Accountability Act (HIPAA) and record retention
requirements; and
b. All NC Medicaid’s clinical (medical) coverage policies, guidelines, policies, provider
manuals, implementation updates, and bulletins published by the Centers for
NC Medicaid Medicaid
Reconstructive and Cosmetic Surgery Clinical Coverage Policy No: 1-O-1
Amended Date: September 1, 2024
24H23 6
Medicare and Medicaid Services (CMS), DHHS, DHHS division(s) or fiscal
contractor(s).
NC Medicaid Medicaid
Reconstructive and Cosmetic Surgery Clinical Coverage Policy No: 1-O-1
Amended Date: September 1, 2024
24H23 7
8.0 Policy Implementation/Revision Information
Original Effective Date: January 1, 1985
Revision Information:
Date
Section Revised
Change
10/01/2008
Throughout
Initial promulgation of current coverage.
07/01/2010
Throughout
Session Law 2009-451, Section 10.31(a) Transition of NC
Health Choice Program administrative oversight from the
State Health Plan to the Division of Medical Assistance
(DMA) in the NC Department of Health and Human
Services.
03/12/2012
Throughout
To be equivalent where applicable to NC DMA’s Clinical
Coverage Policy # 1S-4 under Session Law 2011-145, §
10.41.(b)
03/12/2012
Throughout
Technical changes to merge Medicaid and NCHC current
coverage into one policy.
11/01/2012
Subsection 4.2.1
Moved “Excision of excessive skin and subcutaneous tissue
(including lipectomy) of the following areas are always
considered to be cosmetic when medical necessity for
reconstructive surgery is not met: 1. Thigh. 2. Leg. 3. Hip. 4.
Buttock. 5. Arm. 6. Forearm or hand. 7. Submental fat pad. 8.
All other areas.” to Subsection 4.2.2.
11/01/2012
Throughout
Replaced “recipient” with “beneficiary.”
11/01/2012
Subsection 4.2.1
Added “Note: For breast procedures additional medical
coverage criteria is listed in clinical coverage policy 1A-12,
Breast Surgeries: http://www.ncdhhs.gov/dma/mp/.
10/01/2015
All Sections and
Attachments
Updated policy template language and added ICD-10 codes
to comply with federally mandated 10/1/2015
implementation where applicable.
01/01/2016
Subsection
4.2.1.a
Deleted, “Electrolysis for hirsutism.” Added “Hair removal-
any method.”
03/15/2019
Table of Contents
Added, “To all beneficiaries enrolled in a Prepaid Health
Plan (PHP): for questions about benefits and services
available on or after November 1, 2019, please contact your
PHP.”
03/15/2019
All Sections and
Attachments
Updated policy template language.
01/3/2020
Table of Contents
Updated policy template language, “To all beneficiaries
enrolled in a Prepaid Health Plan (PHP): for questions about
benefits and services available on or after implementation,
please contact your PHP.”
01/3/2020
Attachment A
Added, “Unless directed otherwise, Institutional Claims must
be billed according to the National Uniform Billing
Guidelines. All claims must comply with National Coding
Guidelines”.
01/15/2023
Added 1A-9, Blepharoplasty/Blepharoptosis (Eyelid Repair)
and 1-O-2 Craniofacial Surgery to the Related Clinical Policy
Coverage list
NC Medicaid Medicaid
Reconstructive and Cosmetic Surgery Clinical Coverage Policy No: 1-O-1
Amended Date: September 1, 2024
24H23 8
Date
Section Revised
Change
01/15/2023
Throughout
policy
Changed the word “patient” and “recipient” to beneficiary.
Made text gender neutral.
06/01/2023
All Sections and
Attachments
Updated policy template language due to North Carolina
Health Choice Program’s move to Medicaid. Policy posted
6/1/2023 with an effective date of 4/1/2023.
12/15/2023
Fixed minor formatting issue; posting and amended date not
changed.
09/01/2024
Page 1
Added 1A-15, Surgery for Clinically Severe or Morbid
Obesity, 1-O-3, Keloid Excision and Scar Revision and 1-O-
5, Rhinoplasty and/or Septoplasty under Related Clinical
Coverage Policies.
09/01/2024
Subsection 1.0
Updated the definitions of Reconstructive and Cosmetic
Surgery.
09/01/2024
Subsection
3.2.1.b.
Added the text “accidental injury.”
09/01/2024
Subsection
3.2.1.d.
Removed text that included a non-inclusive list of examples.
09/01/2024
Subsection
4.2.1(b)
Removed text that included a non-inclusive list of examples.
09/01/2024
Subsection 5.1
Removed “The provider shall obtain prior approval before
rendering either cosmetic or reconstructive surgery”
09/01/2024
Subsection 5.2
Added Note: For Medicaid coverage criteria and prior
approval requirements for dental, breast, brow, craniofacial,
bariatric, rhinoplasty, keloid and scar revision procedures,
refer to criteria in specific policies available at
https://medicaid.ncdhhs.gov/. Clinical Coverage Policy 1-O-1
does not apply to these services.
09/01/2024
Subsection 5.2.2
Clarified language to state the rendering provider must
submit the PA request
09/01/2024
Subsection 5.3
Removed subsection and added dental to the Note in
subsection 5.2
09/01/2024
Throughout the
policy
Clarifying language and the removal of partial non-inclusive
lists.
NC Medicaid Medicaid
Reconstructive and Cosmetic Surgery Clinical Coverage Policy No: 1-O-1
Amended Date: September 1, 2024
24H23 9
Attachment A: Claims-Related Information
Provider(s) shall comply with the NCTracks Provider Claims and Billing Assistance Guide, Medicaid
bulletins, fee schedules, NC Medicaid’s clinical coverage policies and any other relevant documents for
specific coverage and reimbursement for Medicaid:
A. Claim Type
Professional (CMS-1500/837P transaction)
Unless directed otherwise, Institutional Claims must be billed according to the National Uniform
Billing Guidelines. All claims must comply with National Coding Guidelines.
B. International Classification of Diseases and Related Health Problems, Tenth
Revisions, Clinical Modification (ICD-10-CM) and Procedural Coding System (PCS)
Provider(s) shall report the ICD-10-CM and Procedural Coding System (PCS) to the highest level
of specificity that supports medical necessity. Provider(s) shall use the current ICD-10 edition and
any subsequent editions in effect at the time of service. Provider(s) shall refer to the applicable
edition for code description, as it is no longer documented in the policy.
C. Code(s)
Provider(s) shall report the most specific billing code that accurately and completely describes the
procedure, product or service provided. Provider(s) shall use the Current Procedural Terminology
(CPT), Health Care Procedure Coding System (HCPCS), and UB-04 Data Specifications Manual
(for a complete listing of valid revenue codes) and any subsequent editions in effect at the time of
service. Provider(s) shall refer to the applicable edition for the code description, as it is no longer
documented in the policy.
If no such specific CPT or HCPCS code exists, then the provider(s) shall report the procedure,
product or service using the appropriate unlisted procedure or service code.
Providers should contact the DMA fiscal agent to check service coverage or prior approval status.
Unlisted Procedure or Service
CPT: The provider(s) shall refer to and comply with the Instructions for Use of the CPT
Codebook, Unlisted Procedure or Service, and Special Report as documented in the current CPT in
effect at the time of service.
HCPCS: The provider(s) shall refer to and comply with the Instructions For Use of HCPCS
National Level II codes, Unlisted Procedure or Service and Special Report as documented in the
current HCPCS edition in effect at the time of service.
D. Modifiers
Provider(s) shall follow applicable modifier guidelines.
E. Billing Units
Provider(s) shall report the appropriate procedure code(s) used which determines the billing
unit(s).
F. Place of Service
Inpatient Hospital, Outpatient Hospital, Office, Clinic, Ambulatory Surgery Center.
NC Medicaid Medicaid
Reconstructive and Cosmetic Surgery Clinical Coverage Policy No: 1-O-1
Amended Date: September 1, 2024
24H23 10
G. Co-payments
For Medicaid refer to Medicaid State Plan:
https://medicaid.ncdhhs.gov/meetings-notices/medicaid-state-plan-public-notices
H. Reimbursement
Provider(s) shall bill their usual and customary charges.
For a schedule of rates, refer to: https://medicaid.ncdhhs.gov/
