Cosmetic and Reconstructive Procedures
Page 1 of 7
UnitedHealthcare Community Plan Medical Policy
Effective 11/01/2023
Proprietary Information of UnitedHealthcare. Copyright 2023 United HealthCare Services, Inc.
UnitedHealthcare
®
Community Plan
Medical
Policy
Cosmetic and Reconstructive Procedures
Policy Number: CS027.Z
Effective Date: November 1, 2023
Instructions for Use
Table of Contents Page
Application ............................................................................. 1
Coverage Rationale .............................................................. 2
Definitions .............................................................................. 2
Applicable Codes .................................................................. 2
Description of Services ......................................................... 6
Benefit Considerations .......................................................... 6
U.S. Food and Drug Administration ...................................... 6
References ............................................................................ 6
Policy History/Revision Information ...................................... 6
Instructions for Use ............................................................... 7
Application
This Medical Policy does not apply to the states listed below; refer to the state-specific policy/guideline, if noted:
Related Community Plan Policies
• Breast Reconstruction
• Breast Reduction Surgery
• Brow Ptosis and Eyelid Repair
• Gender Dysphoria Treatment
• Liposuction for Lipedema
• Omnibus Codes
• Orthognathic (Jaw) Surgery
• 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
Commercial Policy
•
Cosmetic and Reconstructive Procedures
State
Policy/Guideline
Indiana
None
Kentucky
Cosmetic and Reconstructive Procedures (for Kentucky Only)
Louisiana
Cosmetic and Reconstructive Procedures (for Louisiana Only)
Mississippi
Cosmetic and Reconstructive Procedures (for Mississippi Only)
Nebraska
Cosmetic and Reconstructive Procedures (for Nebraska Only)
New Jersey
Cosmetic and Reconstructive Procedures (for New Jersey Only)
New Mexico
Cosmetic and Reconstructive Procedures (for New Mexico Only)
North Carolina
Cosmetic and Reconstructive Procedures (for North Carolina Only)
Ohio
Cosmetic and Reconstructive Procedures (for Ohio Only)
Pennsylvania
Cosmetic and Reconstructive Procedures (for Pennsylvania Only)
Tennessee
Cosmetic and Reconstructive Procedures (for Tennessee Only)
Cosmetic and Reconstructive Procedures
Page 2 of 7
UnitedHealthcare Community Plan Medical Policy
Effective 11/01/2023
Proprietary Information of UnitedHealthcare. Copyright 2023 United HealthCare Services, Inc.
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.
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 generally not covered. 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
generally 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.
Definitions
The following definitions may not apply to all plans. Refer to the federal, state, and contractual requirements 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.
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: Reconstructive Surgery is carried out on atypical structures of the body, caused by congenital
defects, developmental abnormalities, trauma, infection, tumors, or disease. Reconstructive Surgery is commonly
performed to restore function but may also be performed to approximate a normal appearance (Freeman, 2023).
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 federal, state, or contractual requirements 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
Page 3 of 7
UnitedHealthcare Community Plan Medical Policy
Effective 11/01/2023
Proprietary Information of UnitedHealthcare. Copyright 2023 United HealthCare Services, Inc.
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
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)
Insertion of tissue expander(s) for other than breast, including subsequent expansion
Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less
Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm
Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less
Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm
Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia,
hands and/or feet; defect 10 sq cm or less
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
Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less
Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0
sq cm
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)
Formation of direct or tubed pedicle, with or without transfer; trunk
Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legs
Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck,
axillae, genitalia, hands or feet
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)
Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (i.e.,
buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae)
Muscle, myocutaneous, or fasciocutaneous flap; trunk
Muscle, myocutaneous, or fasciocutaneous flap; upper extremity
Muscle, myocutaneous, or fasciocutaneous flap; lower extremity
Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel
Free muscle or myocutaneous flap with microvascular anastomosis
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.
Cosmetic and Reconstructive Procedures
Page 4 of 7
UnitedHealthcare Community Plan Medical Policy
Effective 11/01/2023
Proprietary Information of UnitedHealthcare. Copyright 2023 United HealthCare Services, Inc.
Description
The following codes may be cosmetic; review is required to determine if considered cosmetic or
reconstructive.
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
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)
Unlisted procedure, skin, mucous membrane and subcutaneous tissue
Mastopexy
Breast augmentation with implant
Reduction forehead; contouring only
21138 Reduction forehead; contouring and application of prosthetic material or bone graft (includes
obtaining autograft)
Reduction forehead; contouring and setback of anterior frontal sinus wall
Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or
without grafts (includes obtaining autografts)
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)
Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes
obtaining grafts)
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
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
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
Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)
Osteoplasty, facial bones; reduction
Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)
Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)
Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder); partial
Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder); complete
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)
Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach
Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and extracranial
approach
Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement
Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach
Cosmetic and Reconstructive Procedures
Page 5 of 7
UnitedHealthcare Community Plan Medical Policy
Effective 11/01/2023
Proprietary Information of UnitedHealthcare. Copyright 2023 United HealthCare Services, Inc.
Description
The following codes may be cosmetic; review is required to determine if considered cosmetic or
reconstructive.
21268
Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and
extracranial approach
Secondary revision of orbitocraniofacial reconstruction
21295 Reduction of masseter muscle and bone (e.g., for treatment of benign masseteric hypertrophy);
extraoral approach
Reduction of masseter muscle and bone (e.g., for treatment of benign masseteric hypertrophy);
intraoral approach
Unlisted craniofacial and maxillofacial procedure
Reconstruction, toe(s); polydactyly
Repair choanal atresia; intranasal
Repair choanal atresia; transpalatine
Lysis intranasal synechia
Septal or other intranasal dermatoplasty (does not include obtaining graft)
Implantable breast prosthesis, silicone or equal
L8607 Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary
supplies
Injection, Radiesse, 0.1 ml
Injection, sculptra, 0.5 mg
The following codes are considered cosmetic; the codes do not improve a Functional, Physical, or
physiological Impairment.
Subcutaneous injection of filling material (e.g., collagen); 1 cc or less
Subcutaneous injection of filling material (e.g., collagen); 1.1 to 5.0 cc
Subcutaneous injection of filling material (e.g., collagen); 5.1 to 10.0 cc
Subcutaneous injection of filling material (e.g., collagen); over 10.0 cc
Punch graft for hair transplant; 1 to 15 punch grafts
Punch graft for hair transplant; more than 15 punch grafts
Dermabrasion; total face (e.g., for acne scarring, fine wrinkling, rhytids, general keratosis)
Dermabrasion; segmental, face
Dermabrasion; regional, other than face
Dermabrasion; superficial, any site (e.g., tattoo removal)
Abrasion; single lesion (e.g., keratosis, scar)
15787 Abrasion; each additional 4 lesions or less (List separately in addition to code for primary
procedure)
Chemical peel, facial; epidermal
Chemical peel, facial; dermal
Chemical peel, nonfacial; epidermal
Chemical peel, nonfacial; dermal
Cervicoplasty
Rhytidectomy; forehead
Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)
Rhytidectomy; glabellar frown lines
Rhytidectomy; cheek, chin, and neck
Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap
Electrolysis epilation, each 30 minutes
Cosmetic and Reconstructive Procedures
Page 6 of 7
UnitedHealthcare Community Plan Medical Policy
Effective 11/01/2023
Proprietary Information of UnitedHealthcare. Copyright 2023 United HealthCare Services, Inc.
Description
The following codes are considered cosmetic; the codes do not improve a Functional, Physical, or
physiological Impairment.
Malar augmentation, prosthetic material
Ear piercing
Otoplasty, protruding ear, with or without size reduction
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 change or improve 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 federal, state, and contractual
requirements.
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 April 1, 2022)
References
American Medical Association (AMA). CPT
®
Assistant Online. Available at: https://www.ama-assn.org/practice-
management/cpt. Accessed March 16, 2023.
American Society of Plastic Surgeons (ASPS) available at: http://www.plasticsurgery.org/. Accessed April 1, 2022.
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#:~:text=anotia%20and%20microtia%3F-,Anotia%20and%20microtia%20are%20birth%20defects%20of%20
a%20baby%27s%20ear,first%20few%20weeks%20of%20pregnancy. Accessed March 20, 2023.
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 March 16, 2023.
UnitedHealthcare Insurance Company Generic Certificate of Coverage 2018.
Policy History/Revision Information
Date
Summary of Changes
07/01/2024
Application
New Mexico
Added language to indicate this policy does not apply to the state of New Mexico; refer to the
state-specific policy version
03/01/2024
Related Policies
Updated reference link to reflect current policy title for Treatment of Temporomandibular Joint
Disorders
Cosmetic and Reconstructive Procedures
Page 7 of 7
UnitedHealthcare Community Plan Medical Policy
Effective 11/01/2023
Proprietary Information of UnitedHealthcare. Copyright 2023 United HealthCare Services, Inc.
Date
Summary of Changes
11/01/2023
Related Policies
Added reference link to the Medical Policy titled Liposuction for Lipedema
Coverage Rationale
Cosmetic Procedures
Added language to indicate 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 [of the policy]
Removed list of unproven and not medically necessary Cosmetic Procedures
Definitions
Removed definition of:
o Adjacent Tissue Transfer
o Congenital Anomaly
o Cosmetic Procedures
o Injury
o Medically Necessary
o Reconstructive Procedures
o Sickness
Updated definition of:
o Cosmetic Surgery
o Microtia
o Reconstructive Surgery
Applicable Codes
Removed coding clarifications and CPT coding tips
Benefit Considerations (new to policy)
Added language to indicate 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 federal, state, and contractual
requirements
Supporting Information
Updated Description of Services and References sections to reflect the most current information
Archived previous policy version CS027.Y
Instructions for Use
This Medical Policy provides assistance in interpreting UnitedHealthcare standard benefit plans. When deciding coverage,
the federal, state or contractual requirements for benefit plan coverage must be referenced as the terms of the federal,
state or contractual requirements for benefit plan coverage may differ from the standard benefit plan. In the event of a
conflict, the federal, state or contractual requirements for benefit plan coverage govern. Before using this policy, please
check the federal, state or contractual requirements for benefit plan coverage. 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.
UnitedHealthcare may also use tools developed by third parties, such as the InterQual
®
criteria, to assist us in
administering health benefits. The 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.