MG Cosmetic and Reconstructive Surgery Procedures

Medical Policy:

Cosmetic and Reconstructive Surgery Procedures

POLICY NUMBER LAST REVIEW APPROVED BY

EH.CCI.AD.01a August 12, 2022 Medical Policy Committee (MPC)

The treating physician or primary care provider must submit to EmblemHealth, or ConnectiCare, as applicable (hereinafter jointly referred to as

“EmblemHealth”), the clinical evidence that the member meets the criteria for the treatment or surgical procedure. Without this documentation and

information, EmblemHealth will not be able to properly review the request preauthorization or post-payment review. The clinical review criteria expressed

below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. This clinical policy is not intended to pre-empt

the judgment of the reviewing medical director or dictate to health care providers how to practice medicine. Health care providers are expected to exercise

their medical judgment in rendering appropriate care. Health care providers are expected to exercise their medical judgment in rendering appropriate

care.

EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in

the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research

agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical

areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes

further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically

necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs

exclude coverage for services or supplies that EmblemHealth considers medically necessary.

If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. Identification of selected brand names

of devices, tests and procedures in a medical coverage policy is for reference only and is not an endorsement of any one device, test or procedure over

another. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare &

Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication.

EmblemHealth may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™

Care Guidelines 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. EmblemHealth Services Company, LLC, has adopted this policy in providing management,

administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC, and Health

Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. ConnectiCare, an EmblemHealth company, has also

adopted this policy. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc.

Applicable to: EmblemHealth/ConnectiCare Commercial and EmblemHealth Medicaid Plans

Overview

EmblemHealth/ConnectiCare regard the surgical procedures listed in Applicable Coding Table(s) as cosmetic

(unless substantiating documentation is received that would otherwise indicate that the purpose of the procedure

is to restore or improve bodily function or is otherwise medically necessary).

The plan reserves the right to deny coverage for other procedures that are cosmetic and not medically necessary.

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. Please check benefit plan descriptions for details. If there is

a discrepancy between this policy and a member’s plan of benefits, then the provision of the benefits will prevail.

Indications for Coverage

For plans that include benefits for the procedures listed below, the following are eligible for coverage as

reconstructive and medically necessary when all of the following criteria are met:

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 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 patient’s physiological function.

Limitations and Exclusions

The Plan does not cover cosmetic procedures under the following circumstances, including but not limited

to:

 Procedures that correct an anatomical Congenital Anomaly without improving or restoring

physiologic function (i.e, procedures that do not meet the reconstructive criteria in the

Indications for Coverage

section).

 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.

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

 Treatment for spider or varicose veins outside of varicose vein medical policy.

 Ancillary services related to cosmetic procedures that are not considered medically necessary.

 Hair removal or replacement by any means (except when performed in conjunction with

approved services pertaining to gender dysphoria).

Applicable Coding Table(s)

 Table 1: Medical procedures deemed always cosmetic

 Table 2

: Medical procedures that may be cosmetic (review may be required to determine if the

service is cosmetic or reconstructive)

Table 1: Procedure codes deemed always cosmetic

Code Description

11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions

11201

Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof (List

separately in addition to code for primary procedure)

11950

Subcutaneous injection of filling material (eg, collagen)

Exception: NY and Mass HIV-related lipodystrophy mandate

11951

Subcutaneous injection of filling material (eg, collagen)

Exception: NY and Mass HIV-related lipodystrophy mandate

11952

Subcutaneous injection of filling material (eg, collagen)

Exception: NY and Mass HIV-related lipodystrophy mandate

11954

Subcutaneous injection of filling material (eg, collagen)

Exception: NY and Mass HIV-related lipodystrophy mandate

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Code Description

15775 Punch graft for hair transplant

15776 Punch graft for hair transplant: more than 15 punch grafts

15786 Abrasion; single lesion (eg, keratosis, scar)

15787 Abrasion; each additional 4 lesions or less (List separately in addition to code for primary procedure)

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

15832 Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh

15833 Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg

15834 Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip

15835 Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock

15836 Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm

15837 Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand

15838 Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad

15839 Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area

15876 Suction assisted lipectomy; head and neck

15877 Suction assisted lipectomy; trunk

15878 Suction assisted lipectomy; upper extremity

15879 Suction assisted lipectomy; lower extremity

17340 Cryotherapy (CO2 slush, liquid N2) for acne

17360 Chemical exfoliation for acne (eg, acne paste, acid)

17380

Electrolysis epilation, each 30 minutes

Exception, see Gender Affirming/Reassignment medical policies (ConnectiCare, EmblemHealth)

21120 Genioplasty; augmentation (autograft, allograft, prosthetic material)

19355 Correction of inverted nipples

21121 Genioplasty; sliding osteotomy, single piece

21122

Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for

asymmetrical chin)

21123 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)

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Code Description

65760 Keratomileusis

65765 Keratophakia

65767 Epikeratoplasty

65771 Radial keratotomy

69090 Ear piercing

69300 Otoplasty, protruding ear, with or without size reduction

96902

Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient)

to determine telogen and anagen counts, or structural hair shaft abnormality

S0800 Laser in situ keratomileusis (LASIK)

S0810 Photorefractive keratectomy (PRK)

S0812 Phototherapeutic keratectomy (PTK)

S0596 Phakic intraocular lens for correction of refractive error

Table 2: Procedure codes generally deemed cosmetic (review may be required to

determine if the service is cosmetic or reconstructive)

Code Description Comments/Related Policy Links

10040

Acne surgery (eg, marsupialization, opening or

removal of multiple milia, comedones, cysts,

pustules)

May be considered medically necessary when

causing significant impairment of physical or

mechanical function.

See Indications for

Coverage

11920

Tattooing, intradermal introduction of insoluble

opaque pigments to correct color defects of skin,

including micropigmentation

Breast Implants and Reconstruction (ConnectiCare)

Breast Implants and Reconstruction (EmblemHealth)

Gender Affirming/Reassignment Surgery

(ConnectiCare)

Gender Affirming/Reassignment Surgery

(EmblemHealth)

11921 Tattooing, intradermal introduction

Breast Implants and Reconstruction (ConnectiCare)

Breast Implants and Reconstruction (EmblemHealth)

Gender Affirming/Reassignment Surgery

(ConnectiCare)

Gender Affirming/Reassignment Surgery

(EmblemHealth)

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Code Description Comments/Related Policy Links

11922 Tattooing, intradermal introduction

Breast Implants and Reconstruction (ConnectiCare)

Breast Implants and Reconstruction (EmblemHealth)

Gender Affirming/Reassignment Surgery

(ConnectiCare)

Gender Affirming/Reassignment Surgery

(EmblemHealth)

11960

Insertion of tissue expander(s) for other than breast,

including subsequent expansion

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

11971

Removal of tissue expander(s) without insertion of

prosthesis

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

Also applicable — MCG General Surgery or Procedure

GRG (SG-GS)

15730

Midface flap (ie, zygomaticofacial flap) with

preservation of vascular pedicle(s)

May be considered medically necessary when

causing significant impairment of physical or

mechanical function.

See Indications for

Coverage

Also applicable — MCG Wound and Skin

Management GRG (PG-WS)

15733

Muscle, myocutaneous, or fasciocutaneous flap; head

and neck with named vascular pedicle (ie,

buccinators, genioglossus, temporalis, masseter,

sternocleidomastoid,levator scapulae)

May be considered medically necessary when

causing significant impairment of physical or

mechanical function.

See Indications for

Coverage

Also applicable — MCG Wound and Skin

Management GRG (PG-WS)

15769

Grafting of autologous soft tissue, other, harvested

by direct excision (eg, fat, dermis, fascia)

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

Breast Implants and Reconstruction (ConnectiCare)

Breast Implants and Reconstruction (EmblemHealth)

15771

Grafting of autologous fat harvested by liposuction

technique to trunk, breasts, scalp, arms, and/or legs;

50 cc or less injectate

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

Breast Implants and Reconstruction (ConnectiCare)

Breast Implants and Reconstruction (EmblemHealth)

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Code Description Comments/Related Policy Links

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)

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

Breast Implants and Reconstruction (ConnectiCare)

Breast Implants and Reconstruction (EmblemHealth)

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

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

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)

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

15780

Dermabrasion; total face (eg, for acne scarring, fine

wrinkling, rhytids, general keratosis)

Dermabrasion (ConnectiCare)

Dermabrasion (EmblemHealth)

15781 Dermabrasion; segmental, face

Dermabrasion (ConnectiCare)

Dermabrasion (EmblemHealth)

15782 Dermabrasion; regional, other than face

Dermabrasion (ConnectiCare)

Dermabrasion (EmblemHealth)

15783

Dermabrasion; superficial, any site (eg, tattoo

removal)

Dermabrasion (ConnectiCare)

Dermabrasion (EmblemHealth)

15788 Chemical peel, facial; epidermal

Chemical Peels (ConnectiCare)

Chemical Peels (EmblemHealth)

15789 Chemical peel, facial; dermal

Chemical Peels (ConnectiCare)

Chemical Peels (EmblemHealth)

15792 Chemical peel, nonfacial; epidermal

Chemical Peels (ConnectiCare)

Chemical Peels (EmblemHealth)

15793 Chemical peel, nonfacial; dermal

Chemical Peels (ConnectiCare)

Chemical Peels (EmblemHealth)

15820 Blepharoplasty, lower eyelid;

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

15821

Blepharoplasty, lower eyelid; with extensive

herniated fat pad

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

15822 Blepharoplasty, upper eyelid;

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

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Code Description Comments/Related Policy Links

15823

Blepharoplasty, upper eyelid; with excessive skin

weighting down lid

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

15830

Excision, excessive skin and subcutaneous tissue

(includes lipectomy); abdomen, infraumbilical

panniculectomy

Abdominoplasty/Panniculectomy (ConnectiCare)

Abdominoplasty/Panniculectomy (EmblemHealth)

15847 Excision, excessive skin and subcutaneous tissue

(includes lipectomy), abdomen (eg, abdominoplasty)

(includes umbilical transposition and fascial plication)

(List separately in addition to code for primary

procedure)

Abdominoplasty/Panniculectomy (ConnectiCare)

Abdominoplasty/Panniculectomy (EmblemHealth)

17106

Destruction of cutaneous vascular proliferative

lesions (eg, laser technique); less than 10 sq cm

Pulse Dye Laser Therapy for Cutaneous Vascular

Lesions (ConnectiCare)

Pulse Dye Laser Therapy for Cutaneous Vascular

Lesions (EmblemHealth)

17107

Destruction of cutaneous vascular proliferative

lesions (eg, laser technique); 10.0 to 50.0 sq cm

Pulse Dye Laser Therapy for Cutaneous Vascular

Lesions (ConnectiCare)

Pulse Dye Laser Therapy for Cutaneous Vascular

Lesions (EmblemHealth)

17108

Destruction of cutaneous vascular proliferative

lesions (eg, laser technique); over 50.0 sq cm

Pulse Dye Laser Therapy for Cutaneous Vascular

Lesions (ConnectiCare)

Pulse Dye Laser Therapy for Cutaneous Vascular

Lesions (EmblemHealth)

17380 Electrolysis epilation, each 30 minutes

Considered always cosmetic except in conjunction

with gender affirming/reassignment.

Gender Affirming/Reassignment Surgery

(ConnectiCare)

Gender Affirming/Reassignment Surgery

(EmblemHealth)

17999

Unlisted procedure, skin, mucous membrane and

subcutaneous tissue

Medical records required for review of unlisted codes

19300 Mastectomy for gynecomastia MCG #A-0273 Mastectomy for Gynecomastia

19316 Mastopexy

Breast Implants and Reconstruction (ConnectiCare)

Breast Implants and Reconstruction (EmblemHealth)

MCG #A-0274 Reduction Mammaplasty

(Mammoplasty) (ConnectiCare)

Breast Reduction Mammoplasty (EmblemHealth)

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Code Description Comments/Related Policy Links

19318 Reduction mammaplasty

MCG #A-0274 Reduction Mammaplasty

(Mammoplasty) (ConnectiCare)

Breast Reduction Mammoplasty (EmblemHealth)

Gender Affirming/Reassignment Surgery

(ConnectiCare)

Gender Affirming/Reassignment Surgery

(EmblemHealth)

19325

Mammaplasty, augmentation; with prosthetic

implant

Breast Implants and Reconstruction (ConnectiCare)

Breast Implants and Reconstruction (EmblemHealth)

19340

Immediate insertion of breast prosthesis following

mastopexy, mastectomy or in reconstruction (unless

diagnosis of breast cancer is reported)

Breast Implants and Reconstruction (ConnectiCare)

Breast Implants and Reconstruction (EmblemHealth)

19342

Delayed insertion of breast prosthesis following

mastopexy, mastectomy or in reconstruction (unless

diagnosis of breast cancer is reported)

Breast Implants and Reconstruction (ConnectiCare)

Breast Implants and Reconstruction (EmblemHealth)

21086

Impression and custom preparation; auricular

prosthesis

May be considered medically necessary when

causing significant impairment of physical or

mechanical function.

See Indications for Coverage

21087 Impression and custom preparation; nasal prosthesis

May be considered medically necessary when

causing significant impairment of physical or

mechanical function.

See Indications for Coverage

21137 Reduction forehead; contouring only

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21138

Reduction forehead; contouring and application of

prosthetic material or bone graft (includes obtaining

autograft)

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21139

Reduction forehead; contouring and setback of

anterior frontal sinus wall

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21172

Reconstruction superior-lateral orbital rim and lower

forehead, advancement or alteration, with or without

grafts (includes obtaining autografts)

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

Page 9 of 10

Code Description Comments/Related Policy Links

21175

Reconstruction, bifrontal, superior-lateral orbital rims

and lower forehead, advancement or alteration (eg,

plagiocephaly, trigonocephaly, brachycephaly), with

or without grafts (includes obtaining autografts

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21179

Reconstruction, entire or majority of forehead and/or

supraorbital rims; with grafts (allograft or prosthetic

material)

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21180

Reconstruction, entire or majority of forehead and/or

supraorbital rims; with autograft (includes obtaining

grafts)

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21181

Reconstruction by contouring of benign tumor of

cranial bones (eg, fibrous dysplasia), extracranial

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21182

Reconstruction of orbital walls, rims, forehead,

nasoethmoid complex following intra- and

extracranial excision of benign tumor of cranial bone

(eg, fibrous dysplasia), with multiple autografts

(includes obtaining grafts); total area of bone grafting

less than 40 sq cm

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21183

Reconstruction of orbital walls, rims, forehead,

nasoethmoid complex following intra- and

extracranial excision of benign tumor of cranial bone

(eg, fibrous dysplasia), with multiple autografts

(includes obtaining grafts); total area of bone grafting

greater than 40 sq cm but less than 80 sq cm

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21184

Reconstruction of orbital walls, rims, forehead,

nasoethmoid complex following intra- and

extracranial excision of benign tumor of cranial bone

(eg, fibrous dysplasia), with multiple autografts

(includes obtaining grafts); total area of bone grafting

greater than 80 sq cm

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21230

Graft; rib cartilage, autogenous, to face, chin, nose or

ear (includes obtaining graft)

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21235

Graft; ear cartilage, autogenous, to nose or ear

(includes obtaining graft)

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

Page 10 of 11

Code Description Comments/Related Policy Links

21242 Arthroplasty, temporomandibular joint, with allograft

Orthognathic Surgery (ConnectiCare)

Orthognathic Surgery (EmblemHealth)

21243

Arthroplasty, temporomandibular joint, with

prosthetic joint replacement

Oral Surgery (ConnectiCare)

MCG #A-0523 Temporomandibular Joint Arthroplasty

(EmblemHealth)

21256

Reconstruction of orbit with osteotomies

(extracranial) and with bone grafts (includes

obtaining autografts) (eg, micro-ophthalmia)

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21260

Periorbital osteotomies for orbital hypertelorism,

with bone grafts; extracranial approach

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21261

Periorbital osteotomies for orbital hypertelorism,

with bone grafts; combined intra- and extracranial

approach

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21263

Periorbital osteotomies for orbital hypertelorism,

with bone grafts; with forehead advancement

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21267

Orbital repositioning, periorbital osteotomies,

unilateral, with bone grafts; extracranial approach

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21268

Orbital repositioning, periorbital osteotomies,

unilateral, with bone grafts; combined intra- and

extracranial approach

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21275

Secondary revision of orbitocraniofacial

reconstruction

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21280 Medial canthopexy (separate procedure)

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

21282 Lateral canthopexy

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

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Code Description Comments/Related Policy Links

21740

Reconstructive repair of pectus excavatum or

carinatum; open

Surgical Correction of Chest Wall Deformities

(ConnectiCare)

Surgical Correction of Chest Wall Deformities

(EmblemHealth)

21742

Reconstructive repair of pectus excavatum or

carinatum; minimally invasive approach (Nuss

procedure), without thoracoscopy

Surgical Correction of Chest Wall Deformities

(ConnectiCare)

Surgical Correction of Chest Wall Deformities

(EmblemHealth)

21743

Reconstructive repair of pectus excavatum or

carinatum; minimally invasive approach (Nuss

procedure), with thoracoscopy

Surgical Correction of Chest Wall Deformities

(ConnectiCare)

Surgical Correction of Chest Wall Deformities

(EmblemHealth)

28344 Reconstruction, toe(s); polydactyly

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

30400

Rhinoplasty, primary; lateral and alar cartilages

and/or elevation of nasal tip

Rhinoplasty (ConnectiCare)

Rhinoplasty (EmblemHealth)

30410

Rhinoplasty, primary; complete, external parts

including bony pyramid, lateral and alar cartilages,

and/or elevation of nasal tip

Rhinoplasty (ConnectiCare)

Rhinoplasty (EmblemHealth)

30420 Rhinoplasty, primary; including major septal repair

Rhinoplasty (ConnectiCare)

Rhinoplasty (EmblemHealth)

30430

Rhinoplasty, secondary; minor revision (small amount

of nasal tip work)

Rhinoplasty (ConnectiCare)

Rhinoplasty (EmblemHealth)

30435

Rhinoplasty, secondary; intermediate revision (bony

work with osteotomies)

Rhinoplasty (ConnectiCare)

Rhinoplasty (EmblemHealth)

30450

Rhinoplasty, secondary; major revision (nasal tip work

and osteotomies)

Rhinoplasty (ConnectiCare)

Rhinoplasty (EmblemHealth)

30460

Rhinoplasty for nasal deformity secondary to

congenital cleft lip and/or palate, including columellar

lengthening; tip only

Rhinoplasty (ConnectiCare)

Rhinoplasty (EmblemHealth)

30462

Rhinoplasty for nasal deformity secondary to

congenital cleft lip and/or palate, including columellar

lengthening; tip, septum, osteotomies

Rhinoplasty (ConnectiCare)

Rhinoplasty (EmblemHealth)

30540 Repair choanal atresia; intranasal

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

Page 12 of 13

Code Description Comments/Related Policy Links

30545 Repair choanal atresia; transpalatine

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

30560 Lysis intranasal synechia

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

30620

Septal or other intranasal dermatoplasty (does not

include obtaining graft)

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

36468

Injection of sclerosant for spider veins

(telangiectasia), limb or trunk

See Varicose Vein Treatment Limitations and

Exclusions

Varicose Vein Treatment (ConnectiCare)

Varicose Vein Treatment (EmblemHealth)

36469

Single or multiple injections of sclerosing solutions,

spider veins (telangiectasia); face

See Varicose Vein Treatment Limitations and

Exclusions

Varicose Vein Treatment (ConnectiCare)

Varicose Vein Treatment (EmblemHealth)

36470

Injection of sclerosant; single incompetent vein

(other than telangiectasia)

See Varicose Vein Treatment Limitations and

Exclusions

Varicose Vein Treatment (ConnectiCare)

Varicose Vein Treatment (EmblemHealth)

36471

Injection of sclerosing solution sclerosant; multiple

incompetent veins, (other than telangiectasia), same

leg

See Varicose Vein Treatment Limitations and

Exclusions

Varicose Vein Treatment (ConnectiCare)

Varicose Vein Treatment (EmblemHealth)

40500

Vermilionectomy (lip shave), with mucosal

advancement

May be considered medically necessary when

causing significant impairment of physical or

mechanical function.

See Indications for Coverage

55970 Intersex surgery; male to female

Gender Affirming/Reassignment Surgery

(ConnectiCare)

Gender Affirming/Reassignment Surgery

(EmblemHealth)

55980 Intersex surgery; female to male

Gender Affirming/Reassignment Surgery

(ConnectiCare)

Gender Affirming/Reassignment Surgery

(EmblemHealth)

Page 13 of 14

Code Description Comments/Related Policy Links

67900

Repair of brow ptosis (supraciliary, mid-forehead or

coronal approach)

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

67901

Repair of blepharoptosis; frontalis muscle technique

with suture or other material (eg, banked fascia)

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

67902

Repair of blepharoptosis; frontalis muscle technique

with autologous fascial sling (includes obtaining

fascia)

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

67903

Repair of blepharoptosis; (tarso) levator resection or

advancement, internal approach

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

67904

Repair of blepharoptosis; (tarso) levator resection or

advancement, external approach

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

67906

Repair of blepharoptosis; superior rectus technique

with fascial sling (includes obtaining fascia)

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

67908

Repair of blepharoptosis; conjunctivo-tarso-Muller's

muscle-levator resection (eg, Fasanella-Servat type)

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

67909 Reduction of overcorrection of ptosis

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

67911 Correction of lid retraction Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

67912

Correction of lagophthalmos, with implantation of

upper eyelid lid load (eg, gold weight)

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

67914 Repair of ectropion; suture

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

67915 Repair of ectropion; thermocauterization

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

67916 Repair of ectropion; excision tarsal wedge

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

67917

Repair of ectropion; extensive (eg, tarsal strip

operations)

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

67921 Repair of entropion; suture

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

67922 Repair of entropion; thermocauterization

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

67923 Repair of entropion; excision tarsal wedge

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

Page 14 of 15

Code Description Comments/Related Policy Links

67924

Repair of entropion; extensive (eg, tarsal strip or

capsulopalpebral fascia repairs operation)

Blepharoplasty (ConnectiCare)

Blepharoplasty (EmblemHealth)

67950 Canthoplasty (reconstruction of canthus)

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

67961

Excision and repair of eyelid, involving lid margin,

tarsus, conjunctiva, canthus, or full thickness, may

include preparation for skin graft or pedicle flap with

adjacent tissue transfer or rearrangement; up to one-

fourth of lid margin

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

67966

Excision and repair of eyelid, involving lid margin,

tarsus, conjunctiva, canthus, or full thickness, may

include preparation for skin graft or pedicle flap with

adjacent tissue transfer or rearrangement; over one-

fourth of lid margin

Medical record review required. May be considered

medically necessary when causing significant

impairment of physical or mechanical function.

See Indications for Coverage

96912

Photochemotherapy; psoralens and ultraviolet A

(PUVA)

Phototherapy, Photochemotherapy and

Photodynamic Therapy for Dermatologic Conditions

(ConnectiCare)

Phototherapy, Photochemotherapy and

Photodynamic Therapy for Dermatologic Conditions

(EmblemHealth)

96913

Photochemotherapy (Goeckerman and/or PUVA) for

severe photoresponsive dermatoses requiring at least

four to eight hours of care under direct supervision of

the physician (includes application of medication and

dressings)

Phototherapy, Photochemotherapy and

Photodynamic Therapy for Dermatologic Conditions

(ConnectiCare)

Phototherapy, Photochemotherapy and

Photodynamic Therapy for Dermatologic Conditions

(EmblemHealth)

Definitions

Cosmetic surgery Cosmetic surgery procedures are those intended solely to refine or reshape structures or

surfaces that are not functionally impaired. They are performed to improve appearance or

self-esteem, or for other psychological, psychiatric, or emotional reasons.

Cosmetic surgery is differentiated from reconstructive surgery, which is generally designed to

improve function, but will usually include an improvement in appearance of the body area

involved.

Cosmetic surgery procedures are usually not considered eligible for coverage. This includes,

but is not limited to, treatments, drugs, products, hospital/facility charges, anesthesia,

pathology/lab fees, radiology fees and professional fees by the surgeon, assistant surgeon,

consultants and attending physicians.

Congenital Anomaly

A physical developmental defect that is present at the time of birth, and that is identified

within the first twelve months of birth

Page 15 of 16

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.

Reconstructive

Procedures

Reconstructive Procedures when the primary purpose of the procedure is either of the

following:

 Treatment of a medical condition

 Improvement or restoration of physiologic function

Reconstructive Procedures include 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. Procedures that correct an anatomical Congenital Anomaly

without improving or restoring physiologic function are considered Cosmetic Procedures.

The fact that you may suffer psychological consequences or socially avoidant behavior

because 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.

References

American Medical Association (AMA). CPT® Assistant Online. https://www.ama-assn.org/practicemanagement/cpt. Accessed

August 24, 2022.

American Society of Plastic Surgeons (ASPS). https://www.plasticsurgery.org. Accessed August 24, 2022.

EmblemHealth/ConnectiCare Certificates of Coverage

Centers for Medicare & Medicaid Services. Women's Health and Cancer Rights Act (WHCRA).

https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/whcra_factsheet

. Accessed August 24,

2022.

U.S. Department of Labor. Women’s Health and Cancer Rights Act (WHCRA). https://www.dol.gov/agencies/ebsa/laws-and-

regulations/laws/whcra. Accessed August 24, 2022.

Revision History

Company(ies) DATE REVISION

EmblemHealth/ConnectiCare Aug. 12, 2022 Moved the following CPT codes to always cosmetic table:

11200, 11201, 15832, 15833, 15834, 15835, 15836, 15837,

15838, 15839, 15876, 15877, 15878, 15879 and 65771

EmblemHealth/ConnectiCare Jun. 29, 2022 Removed CPT codes 17110 and 17111

EmblemHealth/ConnectiCare May 31, 2022 Added CPT codes 21806 and 21807 to generally cosmetic table

Removed medical record review requirement for CPT codes

10040, 15730, 15733, 40500

EmblemHealth/ConnectiCare Apr. 20, 2022 Re-listed CPT codes 21120–21123 in always cosmetic table to

coincide with NYS Department of Financial Services list of

cosmetic codes

Page 16 of 16

EmblemHealth/ConnectiCare Feb. 15, 2022 Added CPT 15829 to always cosmetic table

Moved CPT codes 21120–21123 from always cosmetic table to

generally cosmetic table with redirect links added to

Obstructive Sleep Apnea Diagnosis and Treatment policies

EmblemHealth/ConnectiCare Nov. 12, 2021 Reformatted/reorganized policy. Consolidated the Individual

ConnectiCare and EmblemHealth Cosmetic Surgery policies

into a co-branded Cosmetic and Reconstructive Surgery policy