Medical policy: Cosmetic and Reconstructive Surgery

Número de política: MP 1.004

Fecha de entrada en vigor: 9/1/2026

Política

Reconstructive surgery is a procedure performed to improve or correct a functional impairment, restore bodily function or correct deformity resulting from birth defect, medical condition or disease, or accidental injury. If the procedure does not meet the definition of reconstructive, it is considered cosmetic. In order for such services to be considered medically necessary, there must be clear and unequivocal documentation in the medical record to support the reconstructive nature of the services. The following services may be considered medically necessary only when performed for the specified diagnosis:

• Canthoplasty/canthopexy when performed to correct the following conditions confirmed by slit lamp corneal exam:
  • Corneal ulceration
  • Desiccation of the corneal epithelium
  • Epiphora
• Dermal chemical peels used to treat individuals with numerous (greater than 10) actinic keratoses or other premalignant skin lesions, such that treatment of the individual lesions becomes impractical;
• Epidermal chemical peels used to treat individuals with active acne that has failed a trial of topical and/or oral antibiotic acne therapy are considered medically necessary. In this setting, superficial chemical peels with 40–70% alpha hydroxy acids are used as a comedolytic therapy (Alpha hydroxy acids can also be used in lower concentrations [8%] without the supervision of a physician);
• Earlobe surgery to repair a “through and through” laceration resulting in a bilobe earlobe;
• A facial prosthesis where there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect.
• Hair removal to prevent recurrence of pilonidal cysts or when ingrown hairs are responsible for repeated painful cysts;
• Lipectomy and liposuction for the excision of excess skin and/or subcutaneous fat (lipedema) where there is documented clinical evidence (including photographs) that the presence of this excess tissue has resulted in the following with failure to respond to conventional treatment:
• Other significant functional impairment; or
• Severe symptomatic conditions including, but not limited to, chronic pain, dermatitis, or skin ulcerations.
• Liposuction for posttraumatic soft tissue deformity, post-traumatic lipoma, and medication induced lipodystrophy;
• Dermal fillers that are approved by the Food and Drug Administration for lipodystrophy syndrome secondary to antiretroviral HIV treatment
• Mohs micrographic surgery (MMS) for the following indications:
• Basal cell carcinomas and squamous cell carcinomas, malignant melanomas* or other skin cancer with malignant potential.

*Malignant melanoma margins in any area are difficult to determine in frozen sections, as is done with MMS. Only in exceptional circumstances should MMS be performed for such lesions. It should be carefully documented in the medical records why MMS was medically necessary.

• The accepted standard of care is to perform Mohs excision and closure on the same day. Medical necessity for delayed closure may be supported by the following:
• Delay for granulation formation to facilitate flap/graft success; or
• Individual was unable to continue with closure on the same day due to physical or psychological discomfort; or
• Due to surgical requirements for large amounts of local anesthesia, individual requires delayed closure to metabolize the anesthesia
• Otoplasty when performed to correct functional hearing impairment (i.e., inability to hear normal conversation);
• Surgical treatment (lasers, dermabrasion, or electrosurgery) for severe disfigurement associated with rhinophyma to sculpt the nose to a normal shape and appearance;
• Rhytidectomy when performed for the correction of a disease state that has caused irreversible facial paralysis or in the treatment of disfiguring burns of the head and neck region;
• Scar revision for the correction of post-infective, post-surgical, or keloid scars when accompanied by functional impairment;
• Scar revision for post-traumatic scars due to accidental injury (Note: prior surgery is not considered accidental injury);
• Surgical excision or incision and drainage of cysts for the treatment of severe cystic acne;

Epidermal chemical peels used to treat photo aged skin, wrinkles, or acne scarring or dermal peels used to treat end-stage acne scarring are considered cosmetic and investigational as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this procedure.

The surgical treatment (e.g., marsupialization, opening, expression) of comedones, or milia, and pustules is considered cosmetic and investigational as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this procedure.

Dermal fillers, if not used for indications as listed above are considered cosmetic and investigational as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this procedure.

Implants for cosmetic purposes are investigational as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this procedure.

Facial prostheses for reasons not listed above are considered cosmetic and investigational as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this procedure.

Abdominoplasty is considered investigational as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this procedure.

Cross-references:

• MP 1.008 Laser Treatment of Port Wine Stains
• MP 1.013 Reduction Mammoplasty for Breast-Related Symptoms
• MP 1.015 Bariatric Surgery
• MP 1.103 Reconstructive Breast Surgery/Management of Breast Implants
• MP 1.144 Gender Affirming Surgery

Variaciones del producto

Esta política solo se aplica a ciertos programas y productos administrados por Capital Blue Cross y está sujeta a variaciones en los beneficios. Consulte la información adicional a continuación.

FEP PPO - Consulte el Manual de Políticas Médicas de FEP.

Descripción/Antecedentes

This policy documents the criteria that distinguish cosmetic from reconstructive surgical services.

Fundamento

N/D

Definiciones

Birth defect refers to an internal or external congenital abnormality that is present at birth that does not develop, appear, or manifest itself later in life.

Cosmetic surgery: An elective procedure performed primarily to restore a person’s appearance by surgically altering a physical characteristic that does not prohibit normal function but is considered unpleasant or unsightly.

Functional impairment is a condition that describes a state where an individual is limited in the performance of basic activities of daily living.

Keloid refers to an overgrowth of collagenous tissue at the site of a skin injury, particularly a wound or surgical incision. The new tissue is elevated, rounded, and firm.

Lipoma is a benign fatty tumor. It is frequently found in multiple sites but is not metastatic.

Exención de responsabilidad

Las políticas médicas de Capital Blue Cross se utilizan para determinar la cobertura de tecnologías, procedimientos, equipos y servicios médicos específicos. Estas políticas médicas no constituyen un consejo médico y están sujetas a cambios según lo permita la ley o la evidencia clínica aplicable de las pautas de tratamiento independientes. Los proveedores que brindan tratamiento son individualmente responsables de los consejos médicos y el tratamiento de los miembros. Estas políticas no son una garantía de cobertura o pago. El pago de las reclamaciones está sujeto a la determinación del programa de beneficios del miembro y la elegibilidad en la fecha del servicio, y a la determinación de que los servicios son médicamente necesarios y apropiados. El procesamiento final de una reclamación se basa en los términos del contrato que se aplican al programa de beneficios del miembro, incluidas las limitaciones y exclusiones de beneficios. Si un proveedor o miembro tiene alguna pregunta sobre esta política médica, debe comunicarse con Servicios para proveedores o Servicios para miembros de Capital Blue Cross.

Información de codificación

Nota: esta lista de códigos puede no ser exhaustiva y los códigos están sujetos a cambios en cualquier momento. La identificación de un código en esta sección no denota cobertura, ya que la cobertura está determinada por los términos de la información de beneficios del miembro. Además, no todos los servicios cubiertos son elegibles para un reembolso por separado.

The following are cosmetic; therefore, not covered:

*Investigational when used for abdominoplasty

Cubierto cuando sea médicamente necesario:

Referencias

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