Skip to main content
HealthPartners

Coverage criteria policies

Cosmetic surgery / treatments

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own 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

All requests for coverage of cosmetic surgery/treatment require prior authorization.

Submission of GA modifier wavier is required when requesting services which are always considered a cosmetic service and therefore never covered. (See Coverage section and list of non-covered indications below).

Coverage

Services that are performed to enhance or change the appearance and are not necessary to preserve the health of an individual are always considered to be cosmetic and are not eligible for coverage. This policy is meant to supplement a member’s contracted benefit plan. In the event of a conflict, a member’s benefit plan document always supersedes the information in this coverage policy. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. The provider and facility will be liable for payment unless:

  1. The provider notifies the member that a specific service has been determined by HealthPartners to be cosmetic and
  2. The member signs a waiver agreeing to pay for the specific non-covered service being rendered and
  3. The claim has been billed with a GA modifier indicating such. If the member has signed a waiver agreeing to pay for the specific service then the member will be liable for payment.

Indications that may be covered

The following are examples of procedures or treatments which, depending upon the situation, may be considered cosmetic or medically necessary. For this reason, HealthPartners has developed specific coverage policies to address them. Generally, these procedures require prior authorization. Please refer to the following individual policies for coverage criteria and documentation requirements:

  • Blepharoplasty/ Brow Lift/Ptosis Repair
  • Breast Surgery (Augmentation/Implant Removal/Lift)
  • Breast Reduction Surgery (Reduction Mammoplasty)
  • Gynecomastia Surgery for Males
  • Hemangioma Treatment
  • Hyperhidrosis Treatment (with Thoracic Sympathectomy)
  • Laser Treatment for Skin Conditions
  • Orthognathic Surgery
  • Panniculectomy
  • Radiofrequency ablation applications
  • Rhinoplasty - plastic surgery to alter nasal appearance
  • Scar Revision/Keloids
  • Sclerotherapy for varicose veins
  • Weight Loss Surgery

Indications that are not covered

Contractual benefits prohibit the coverage of cosmetic services, including those listed below. Please note that while this portion of the policy addresses many common procedures, it does not address all procedures that might be considered to be cosmetic. Per the member contract, the HealthPartners Medical Policy Department, in collaboration with HealthPartners Medical Directors, reserves the right to review and deny coverage for other procedures that are deemed cosmetic.

  1. Abdominoplasty or tummy tuck (See Panniculectomy coverage policy)
  2. Any skin lesion treated or removed for solely cosmetic purposes
  3. Dermabrasion treatment (except for pre-cancerous and cancerous conditions)
  4. Diastasis Recti repair (See Panniculectomy coverage policy)
  5. Earlobe repair, except in the event of acute, traumatic injury.
  6. Ear or body piercing
  7. Electrolysis or laser hair removal (including treatment of pseudofolliculitis barbae).
  8. Face lifts (rhytidectomy) or other related procedures to remove wrinkles or diminish the aging process
  9. Fat grafts to any area unless performed as an integral part of another covered procedure
  10. Hair transplants or repair of any congenital or acquired hair loss
  11. Injections of Botox (botulinum toxin) to treat wrinkles
  12. Injections of dermal fillers to improve the skin’s contour or treat wrinkles, scars, or lipoatrophy. Examples include but are not limited to Artefill, Bellafill, Belotero, Captique, Cosmoderm, Elevess, Evolence, Fibrel, Hylaform (Hylan B Gel), Juvederm, Prevelle Silk, Radiesse, Restylane, Sculptra, Zyderm and Zyplast.
  13. Laser facial resurfacing for treatment of acne scarring
  14. Laser treatment of rosacea, a common skin condition in which certain facial blood vessels enlarge, giving the cheeks and nose a flushed appearance
  15. Laser treatment for removal of spider veins (telangiectasia or spider angioma)
  16. Liposuction of any area unless performed as an integral part of another covered procedure
  17. Mesotherapy (injection of pharmaceutical and homeopathic medications, plant extracts, vitamins and other ingredients into the tissue beneath the skin to sculpt body contours by lysing subcutaneous fat).
  18. Otoplasty surgery for protruding ears
  19. Removal of excessive skin, thigh (thighplasty), leg, hip, buttock, arm(brachioplasty), forearm, hand, or neck (cervicoplasty)
  20. Tattoo removal
  21. Testicular implants for congenitally absent testes
  22. Vaginal rejuvenation procedures (including clitoral reduction, designer laser vaginoplasty, G-spot amplification, pubic liposuction or lift, reduction of labia minora, labia majora surgery or re-shaping, labiaplasty, or vaginal tightening)

Definitions

Cosmetic The term given to surgery or treatment which is performed to enhance or change the appearance of an abnormal or normal body part and is not necessary to preserve the health of an individual.

If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

11950

Subcutaneous injection of filling material (eg, collagen); 1 cc or less

11951

Subcutaneous injection of filling material (eg, collagen); 1.1 to5.0 cc

11952

Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc

11954

Subcutaneous injection of filling material (eg, collagen); over 10.0 cc

15775

Punch graft for hair transplant; 1 to 15 punch grafts

15776

Punch graft for hair transplant; more than 15 punch grafts

15780

Dermabrasion; Total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)

15781

Dermabrasion; segmental, face

15782

Dermabrasion; regional, other than face

15783

Dermabrasion; superficial, any site (eg, tattoo removal)

15788

Chemical peel, facial; epidermal

15789

Chemical peel, facial; dermal

15792

Chemical peel, non-facial; epidermal

15793

Chemical peel, non-facial; dermal

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

15830

Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infra-umbilical panniculectomy

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

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)

15876

Suction assisted lipectomy; head and neck

15877

Suction assisted lipectomy; trunk

15878

Suction assisted lipectomy; upper extremity

15879

Suction assisted lipectomy; lower extremity

17106

Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm

17107

Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm

17108

Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm

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

17380

Electrolysis epilation, each 30 minutes

36469

Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); face

54660

Insertion of testicular prosthesis (separate procedure)

56620

Vulvectomy simple; partial

56810

Perineoplasty, repair of perineum, non-obstetrical (separate procedure)

56800

Plastic repair of introitus

58899

Unlisted procedure, female genital system (non-obstetrical)

69090

Ear piercing

69300

Otoplasty, protruding ear, with or without size reduction

Q2026

Injection, Radiesse 0.1ml

Q2028

Injection, Sculptra 0.5mg

J3490

Injection, unclassified drug (applies to dermal fillers that do not have a specific assigned code)

G0429

Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS)

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

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.

References

  1. American Academy of Otolaryngology-Head and Neck Surgery, Ear Plastic Surgery. Retrieved from http://www.entnet.org/content/patient-health (accessed 3/7/2017).
  2. American Society of Plastic Surgeons, ASPS Recommended Insurance Coverage Criteria for Third-Party Payers- Ear Deformity: Prominent Ears. Retrieved from http://plasticsurgery.org (accessed 3/7/2017)
  3. Cohen, J., Dayan, S. Brandt, S., Nelson, D., Axford-Gatley, R., Theisen, M., & Narins, R., (2013) Systematic Review of Clinical Trials of Small- and Large-Gel-Particle Hyaluronic Acid Injectable Fillers for Aesthetic Soft Tissue Augmentation. Dermatology Surgery, 39:205-231.
  4. Committee on Gynecologic Practice (2007) Vaginal “Rejuvenation and Cosmetic Vaginal Procedures. American Congress of Obstetrics and Gynecologists. http://www.acog.org (accessed 8/12/16).
  5. Committee on Adolescent Health Care (2016) Breast and Labial Surgery in Adolescents. American Congress of Obstetrics and Gynecologists. http://www.acog.org (accessed 8/30/16).
  6. Goldstein, B. and Goldstein, A. Overview of benign lesions of the skin. In: UpToDate, Dellavalle, R. (Ed), UpToDate, Waltham, MA. (Accessed on 6/12/2017).
  7. Goodman, M., Otto, P. Benson, R. Miklos, J., Moore, R., Jason, R., & Gonzalez, F. (2010) A Large Multicenter Outcome Study of Female Genital Plastic Surgery. Journal of Sexual Medicine. 7:1565-1577.
  8. Hayes, Inc. Hayes Medical Technology Directory Report. Laser and Light Therapies for Rosacea. Lansdale, PA: Hayes, Inc.; October, 2007. Reviewed Sept, 2011/Archived November, 2012.
  9. Isaacson, G. Congenital Anomalies of the ear. In: UpToDate, Messner, A. and Firth, H. (Ed), UpToDate, Waltham, MA. (Accessed on 3/21/2017).
  10. Jackson, J. Infectious Folliculitis. In: UpToDate, Rosen, T. (Ed), UpToDate, Waltham, MA. (Accessed on September 20, 2017).
  11. Jayasinghe, S., Guillot, T., Blissoon, L. Greenway, F. (2013) Mesotherapy for local fat reduction. Obesity Reviews. 14: 771-857.
  12. Kogan, Stanley. (2014).The clinical utility of testicular prosthesis placement in children with genital and testicular disorders. Translational Andrology and Urology 3(4): 391-397.
  13. Laube, D. (2010) Cosmetic Procedures in Gynecology. Obstetrics and Gynecology Clinics of North America. 37(2010) xiii-xiv
  14. Lloyd, J., Crouch, N., Minto, C. Liao, L. Creighton, S. (2005) Female Genital Appearance: “normality” unfolds. BJOG: An International Journal of Obstectrics and Gynaecology. 112:643-646.
  15. Nahabedian, M. and Brooks, D. Rectus Abdominus Diastasis. In: Up To Date, Butler, C. and Rosen, M. (Ed), Up To Date, Waltham, MA. (Accessed on August, 2, 2016).
  16. Scorza, A. Scorza, L., Troccola, A., Micci, D., Rauso, R., Curinga, G. (2012) Autologous Fat Transfer for Face Rejuvenation with Tumescent Technique Fat Harvesting and Saline Washing: A Report of 215 Cases. Karger Medical and Scientific Publishers, Dermatology. 224:244-250.