Plastic and Reconstructive Surgery — Coverage Criteria
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Defines when plastic surgery services (congenital deformities, reconstructive procedures, skin treatments, facial and chest surgery, hair removal, panniculectomy, musculoskeletal transplants) are considered medically necessary and the authorization requirements for Blue Cross Blue Shield Massachusetts members.
Panniculectomy statement clarified and definition of significant weight loss clarified; not medically necessary statement added.
Cleft lip/palate statement removed; coverage determined by subscriber certificate.
Laser treatments of port-wine stains or hemangiomas of the face and neck are covered and authorizations are not required for such treatments in children and adults.
Coverage Criteria for Plastic and Reconstructive Surgery
Reconstructive Surgery - General
Covered when ANY of the following reconstructive or restorative criteria are met
Includes correction of scarring after accidental face and neck injuries and treatment of complications of cosmetic surgery when the treatment of the complication is medically necessary to restore function. Only the initial reconstructive repair is covered unless the procedure is normally performed in stages.
Congenital and Developmental Deformities in Children
Congenital/developmental deformities in children may be covered when severe or debilitating including but not limited to:
The child need not have been covered by the payer at birth. Laser treatments of port‑wine stains or hemangiomas of the face and neck are covered and authorizations are not required for such laser treatments in children and adults.
Chest Wall Deformity
Chest wall deformity (pectus) coverage criteria
Haller index threshold of 3.2 is used as a criterion; physician judgment may substitute when risk of compromise is present.
Physician clinical judgment regarding risk of compromise governs coverage for pectus carinatum.
Panniculectomy
Panniculectomy coverage criteria — must meet ALL of the following
Significant weight loss is defined as meeting one of the following: BMI of 30 or less; documented weight loss of 100 pounds or more; or weight loss of 40% or more of the patient's excess body weight. Submission of medical record documentation and preoperative photographs are required. Panniculectomy should be deferred at least 12 months after bariatric surgery with stable weight for at least 6 months.
Skin Treatment and Scar Management
Skin and scar treatments covered when they restore function or treat symptomatic lesions
Removal of excess skin after significant weight loss may be medically necessary when there are recurrent documented rashes, non‑healing ulcers, or a documented functional impairment such as significant difficulty with activities of daily living.
Nose (Rhinoplasty)
Nasal surgery coverage
Ears (Otoplasty)
Ear surgery coverage
Face
Facial plastic surgery coverage
Includes procedures to address functional impairment such as facial nerve palsy.
Hair Removal
Hair removal coverage
Musculoskeletal / Labiaplasty
Other musculoskeletal or genital procedures
Plastic or reconstructive surgery for indications other than those listed is not medically necessary.
Not Medically Necessary / Cosmetic
Procedures considered NOT medically necessary
CPT 15847 (abdominoplasty) is specifically listed as not medically necessary for commercial and Medicare products in this policy.
General coverage disposition and cross-references
Coverage determinations have been revised over time; specific procedures may be covered, not covered, or governed by subscriber certificate or separate policies.
See related policies listed in the policy history and cross‑references for full criteria.
Note: Subscriber certificates exclude coverage for cosmetic services. This policy distinguishes reconstructive procedures that restore bodily function or correct impairments from cosmetic services that are excluded by the subscriber certificate.
Abdominoplasty is explicitly identified in this policy as a cosmetic procedure and is therefore NOT MEDICALLY NECESSARY. The policy states that abdominoplasty is considered cosmetic and NOT MEDICALLY NECESSARY and that panniculectomy (distinct from abdominoplasty) has specific reconstructive criteria.
The policy lists CPT code 15847 (abdominoplasty) — “Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty)” — and designates this procedure as not medically necessary for the described commercial products.
Policy history and cross-referenced entries note that certain services — including abdominoplasty — have been treated as cosmetic and not medically necessary in prior updates, and that coverage for some procedures or repairs may be governed by the subscriber certificate or transferred to other policies. Historically, the policy has clarified that abdominoplasty and similar cosmetic procedures are not covered and that coverage responsibilities for some items are determined by the subscriber certificate.
The policy distinguishes procedures: Diastasis recti repair is considered NOT MEDICALLY NECESSARY. It also states that abdominoplasty is cosmetic and NOT MEDICALLY NECESSARY. By contrast, panniculectomy can be considered reconstructive and MEDICALLY NECESSARY only when all specified criteria are met (performed after significant weight loss to remove a hanging abdominal panniculus of at least grade 2 severity with associated symptoms such as recurrent/refractory skin problems, infections, non-healing ulcers after ≥8 weeks of care, or severe shoulder/neck/back pain interfering with ADLs).
CPT 15847 (abdominoplasty) is explicitly listed in the policy code table for abdominoplasty and is designated as not medically necessary for the commercial and Medicare product types referenced in the policy.
The policy history documents the designation that abdominoplasty is considered cosmetic and not medically necessary (noted in the 12/2018 entry), reinforcing the longstanding exclusion of abdominoplasty as a covered, medically necessary reconstructive procedure.
Coding — CPT / HCPCS / ICD-10
| 17380 | Electrolysis epilation, each 30 minutes |
| 15770 | Graft; derma-fat-fascia |
| 15825 | Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) |
| 15828 | Rhytidectomy; cheek, chin, and neck |
| 15829 | Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap |
| 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 |
| 17110 | Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions |
| 17111 | Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions |
| 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 |
| 56620 | Vulvectomy simple; partial |
| 30400 | Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip |
| 30410 | Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip |
| 30420 | Rhinoplasty, primary; including major septal repair |
| 30430 | Rhinoplasty, secondary; minor revision (small amount of nasal tip work) |
| 30435 | Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) |
| 30450 | Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) |
| 21740 | Reconstructive repair of pectus excavatum or carinatum; open |
| 21742 | Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy |
| 21743 | Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy |
| 15830 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy |
| 69300 | Otoplasty, protruding ear, with or without size reduction |
| 15847 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) |
| No codes listed |
Provider Actions, Prior Authorization and Documentation Requirements
Prior Authorization Required for Inpatient Services
Precertification/preauthorization is required for inpatient procedures described in this policy. Failure to obtain the required inpatient authorization may result in denial of coverage.
- Applicable to all products when the procedure is performed inpatient.
Outpatient Prior Authorization — Procedures and Product-Specific Requirements
Outpatient prior authorization is required for specific procedures and product types as indicated in the policy code tables. Absence of required outpatient authorization may result in denial or noncoverage for the listed procedures.
- Dermabrasion codes (15780–15783) — outpatient prior authorization required for all products.
- Removal of excess skin codes (15832–15839) — outpatient prior authorization required for all products.
- Rhinoplasty codes (30400–30450) — outpatient prior authorization required for all products.
- Lipectomy/liposuction codes (15876–15879) — outpatient prior authorization required for Commercial HMO and PPO products.
- Scar injection codes (11900–11901) — outpatient prior authorization required for Medicare HMO Blue products.
Authorization Manager Entry and PA Procedures
When submitting initial authorization requests use Authorization Manager and follow payer procedures for prior authorization. Enter the facility's NPI or provider ID for where services will be performed and enter the servicing surgeon's NPI or provider ID (not the billing provider). Authorization Manager is the quickest way to review requirements, submit clinical documentation, check case status, and obtain the decision letter.
- Enter facility NPI or provider ID.
- Enter servicing surgeon's NPI or provider ID (not the billing provider).
- Submit required clinical documentation and pre-operative photographs when requested (e.g., panniculectomy).
- Follow current payer Authorization Manager workflows and any plan-specific PA procedures to avoid delays or denials.
Coding, Billing and Benefit Verification
Verify member benefits and coverage prior to submitting requests. Providers must report services using current industry-standard procedure, revenue, and diagnosis codes, including applicable modifiers. Inclusion of a code in the policy does not guarantee coverage — refer to the member's contract benefits in effect at the time of service.
- Report services with the most up-to-date CPT/HCPCS/revenue/ICD-10 codes and applicable modifiers.
- Check the member's contract and benefits to determine coverage or non-coverage for the individual.
- The listed codes in the policy are informational and not an exhaustive list.
Documentation Requirements to Support Medical Necessity
Submission of medical record documentation is required for procedures where medical necessity criteria apply (for example, panniculectomy). Provide documentation of the condition, treatments tried and responses, and pre-operative photographs or measurements when requested. Failure to provide requested documentation may result in denial.
- For panniculectomy: nature of skin condition, treatments attempted and response, pre-operative photographs and measurements as available.
- Provide clinical notes, specialist evaluations, and treatment history as applicable.
Background
This policy defines the scope for plastic and reconstructive surgery: services described include congenital deformities, reconstructive surgery, skin treatments, facial plastic surgery, hair removal, chest wall deformity, and musculoskeletal transplants. It emphasizes that the policy addresses when procedures are considered MEDICALLY NECESSARY to restore physical function or correct impairments from accidents, injuries, birth defects, prior surgery, or disease, and that complications of cosmetic surgery may be medically necessary when treatment of the complication restores function.
Key Definitions
Policy Revision History
Clarified coding information.
Panniculectomy statement clarified; added not medically necessary statement and clarified definition of significant weight loss.
Cleft lip/palate statement removed; coverage is determined by the subscriber certificate; panniculectomy criteria revised and coding information clarified.
Hair transplants removed; coverage determined by the subscriber certificate.
Policy clarified to state laser treatments of port‑wine stains or hemangiomas of the face and neck are covered and authorizations are not required for these treatments in children and adults.
New medically necessary statement added for hair removal to prevent pilonidal cyst recurrence.
Policy clarified to include prior authorization requests submitted using Authorization Manager.
PA table updated to require prior authorization for liposuction/lipectomy for Commercial PPO, EPO, and Commercial Managed Care (HMO and POS); separate column added for Commercial Indemnity, and medically necessary statements on liposuction/lipectomy updated.
New medically necessary statement on lipoma removal added and coding information clarified; transfers of certain surgical procedures to new policy #179 (Orthognathic Surgery) completed.
Medicare information removed; reference to MP #132 (Medicare Advantage Management) for local and national coverage determinations.
Medically necessary statement on removal of excess skin clarified to include functional impairment, such as significant difficulty with activities of daily living.
Age criteria to correct pectus excavatum and pectus carinatum removed.
Abdominoplasty (CPT 15847) designated cosmetic and not medically necessary.
Medically necessary statements regarding mandated coverage for HIV‑associated lipodystrophy syndrome treatment clarified.
Clarified coding information.
Medically necessary criteria for areola tattooing as part of nipple reconstruction clarified; not medically necessary tattoo removal/application criteria clarified.
Policy updated to include mandated coverage for reconstructive services to correct or repair disturbances of body composition caused by HIV‑associated lipodystrophy syndrome.
Liposuction criteria updated to indicate when it is medically necessary; coding information clarified.
Policy #460 (Laser Treatment of Port Wine Stains) retired and related statements transferred or retired as part of the 10/1/2015 consolidations.
Multiple indications and procedures transferred to other policies (e.g., blepharoplasty to #740; chemical peels to #732; nonpharmacologic rosacea treatments to #462; treatment of active acne to #461); coverage for several services determined by subscriber certificate.
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