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HealthPartners

Coverage criteria policies

Reconstructive surgery

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is generally required for reconstructive surgery.

Some scar revision procedures, which may be reconstructive, do not require prior authorization. Please see the Scar revision policy for details

Coverage

Reconstructive surgery is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered - Adults

For adults, the reconstructive surgery must be incidental to or following a surgical procedure resulting from an illness or injury of the involved body part.

Indications that are covered - Children

For children, the requested reconstructive surgery must either:

  1. Be incidental to or following a surgical procedure resulting from an illness or injury of the involved body part, or
  2. Correct a congenital disease or anomaly that results in a functional deficit in a dependent child.

Indications that are not covered

Additional reconstructive surgeries beyond the initial reconstructive surgery are not covered unless:

  1. The reconstruction is being done as a staged procedure, or
  2. The initial reconstructive surgery resulted in a medically adverse or unanticipated outcome.

Definitions

Reconstructive surgery is surgery, incidental to or following surgery, resulting from injury or illness of the involved body part. It can be done to correct a congenital disease or anomaly resulting in a functional defect in a dependent child.

A functional defect is one that interferes with a member’s ability to perform activities of daily living.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

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Policy activity

  • 04/30/1994 - Date of origin
  • 05/01/2017 - Effective date
Review date
  • 05/2017

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