| Abdominoplasty/ panniculectomy |
- Reconstructive if patient meets policy guidelines. See Abdominoplasty joint policy.
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| Blepharoplasty of lower lids |
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| Blepharoplasty of upper lids |
- Cosmetic when done to improve appearance only.
- Reconstructive if criteria are met. Refer the Blepharoplasty and Repair of Brow Ptosis policy.
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| Breast augmentation**/ reconstruction |
- Cosmetic if done solely to improve appearance
- Reconstructive if done following prophylactic mastectomy in high-risk patients. May also be considered reconstructive following medically necessary mastectomy. This would include reconstruction of the nipple and areolar complex. Reconstruction/revision of the contralateral breast may be necessary to provide symmetry between the breasts.
- **See the medical policy titled Reconstructive Breast Surgery/Management of Breast Implants for tattooing the breast/nipple in conjunction with breast reconstruction.
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| Breast reduction |
- Cosmetic if done to improve appearance in the absence of functional deficits
- Reconstructive if policy guidelines are met. See the Breast Reduction Mammoplasty joint policy.
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| Chemical peels** |
- Cosmetic when done for aging skin (e.g., skin damage due to overexposure to sun, etc.), wrinkles, acne scarring, or when using chemical peel and hydrating agents that don’t require physician supervision for application
- Reconstructive when guidelines are met:
Chemical peels performed no more than three to four times in a 12-month period are appropriate as follows:
- Dermal (medium and deep) chemical peels, up to four times per in a 12-month period, used to treat patients with numerous (>10) actinic keratoses or other premalignant skin lesions
- Epidermal (superficial) peels, up to six times in a 12-month period, to treat active acne in patients who have failed other therapy
**Note: Requests for chemical peels should be carefully evaluated to determine if the request is primarily cosmetic in nature. Refer to the Chemical Peels joint policy. |
| Cheek (malar) or chin (genioplasty) implants |
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| Correction of telangiectasias or spider veins |
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| Cryotherapy for skin conditions |
- Cosmetic when used to treat acne scarring or other dermatologic conditions in which the primary purpose is to change or improve appearance when there is no specific functional deficit or imminent health risk. Cryotherapy isn’t recommended for the treatment of active acne vulgaris.
- Reconstructive when used to treat actinic keratosis or other pre-cancerous skin lesions.
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| Dermabrasion/ microdermabrasion |
- Cosmetic when used for treatment of wrinkling, hyperpigmentation or acne scarring. Dermabrasion and microdermabrasion are not recommended for the treatment of active acne vulgaris.
- Reconstructive when used to treat actinic keratosis or other pre-cancerous skin lesions.
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| Dermal fillers |
- Cosmetic when used to improve appearance.
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| Diastasis recti repair absent a true midline hernia |
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| Electrolysis |
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| Excision of excessive skin of the thigh, leg, hip, buttock, arm, forearm, hand, submental fat pad or other areas |
- Cosmetic if the primary purpose is to change or improve appearance when there is no specific functional deficit (e.g., interference with ADLs) or imminent health risk (e.g., infection) that can be removed or improved by the procedure.
- Reconstructive if done to correct a functional problem, including but not limited to, severe rashes or intertrigo, skin ulceration or pain, etc., that hasn’t responded to conventional medical therapy (e.g., topical antifungals, topical or systemic corticosteroids, or local or systemic antibiotics)
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| Excision of glabellar frown lines |
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| Fat grafts |
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| Hairplasty for any form of alopecia |
- Cosmetic. Coverage may be available only for the treatment of the underlying condition. Refer to the Alopecia Treatment joint policy.
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| Insertion or injection of prosthetic material to replace absent adipose tissue |
- Reconstructive only when used to repair a significant deformity from accidental injury, surgery or trauma.
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| Laser resurfacing of the skin |
- Cosmetic when done to treat wrinkling or aging skin, acne scars, telangiectasias or other skin conditions in which the primary purpose is to change or improve appearance when there is no specific functional deficit or imminent health risk. Laser resurfacing isn’t recommended for the treatment of active acne vulgaris.
- Reconstructive when done to treat patients with numerous (>10) actinic keratoses or other pre-malignant or nonmalignant skin lesions when treatment of the individual lesions would be impractical.
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| Laser resurfacing of burn scars (ablative/non-ablative fractional and micro-fractional CO2 laser resurfacing) |
- Reconstructive when used to help correct the abnormal texture and pliability of burn scars
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| Laser treatment of port wine stains |
- Reconstructive if done due to functional impairment related to the port wine stain (e.g., bleeding).
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| Liposuction/suction-assisted lipectomy |
- Cosmetic if it is the sole procedure done.
- Commonly performed on the abdomen (the tummy), buttocks (behind), hips, thighs, knees, chin, upper arms, back and calves.
- Long-term effectiveness of treatment of lower extremity lymphedema hasn’t been established.
- Reconstructive if done in conjunction with covered reconstruction surgery. For example, if a covered breast reduction is done by conventional means, there may be a need for minor liposuction to smooth the edges of the incisions.
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| Otoplasty |
- Cosmetic when done to treat psychological symptomatology or psychosocial complaints related to one’s appearance
- Reconstructive in following circumstances: when done to correct absent or deformed ears due to congenital deformity/absence, trauma or accidental injury.
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| Poly-L-lactic acid injection (e.g., Sculptra®) |
- Cosmetic for all indications, including HIV lipoatrophy
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| Reduction of labia majora and minora, or labiaplasty |
- Cosmetic. In situations where there is discomfort from the condition, these symptoms can be managed with personal hygiene and avoidance of form-fitting clothes.
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| Rhinoplasty |
- Cosmetic if done to improve appearance only
- Reconstructive if done for repair of nasal deformity due to trauma, accidental injury or chronic condition affecting the nasal structures (e.g., Wegener’s granulomatosis).
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| Salabrasion (a technique in which salt or a salt solution is used to abrade the skin, e.g., to remove the pigment from a tattoo or permanent makeup) |
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| Scar revision |
- Cosmetic if scars are asymptomatic
- Reconstructive for the revision of symptomatic scars
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| Tattoo removal |
- Cosmetic if done for the removal of decorative tattoos
- Reconstructive if done for the removal of hyperpigmentation resulting from trauma, surgery or other procedures
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| Testicular prostheses |
- Reconstructive for replacement of congenitally absent testes or testes lost due to disease, injury or surgery.
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| Voice-lifting procedures (e.g., Restylane injections) |
- Cosmetic. Implants or injections of fat or collagen are used to bring vocal cords closer together or to plump cords in an attempt to restore elasticity of vocal cords and reinstate a youthful quality to the patient’s voice
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