Payment Policy: Cosmetic Procedures Form

# Payment Policy: Cosmetic Procedures
Reference Number: CC.PP.024
Product Types: ALL
Effective Date: 01/01/2014
Last Review Date: 11/05/2025

[Coding Implications](Coding Implications) [Revision Log](Revision Log)

See [Important Reminder](Important Reminder) at the end of this policy for important regulatory and legal information.

## Policy Overview
Cosmetic procedures or procedures connected with cosmetic surgery are not reimbursable. The Centers for Medicare and Medicaid Services (CMS) defines cosmetic procedures as “a surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the treatment of the functioning of a malformed body member” that is performed to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem.” These procedures can be performed for medically necessary or cosmetic reasons.

## Application
This policy applies to professional and institutional claims.

## Policy Description


# PAYMENT POLICY
# COSMETIC PROCEDURES

## Coding and Modifier Information
This payment policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT® codes and descriptions are copyrighted 2026, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this payment policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

| CPT/HCPCS Code | Descriptor |
|---------------|------------|
| 11920 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less |
| 11921 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm |
| 11922 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure |
| 11950 | Subcutaneous injection of filling material (eg, collagen); 1 cc or less |
| 11951 | Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 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) |
| 15786 | Abrasion; single lesion (eg, keratosis, scar) |
| 15787 | Abrasion; each additional 4 lesions or less (List separately in addition to code for primary procedure) |
| 15788 | Chemical peel, facial; epidermal |
| 15789 | Chemical peel, facial; dermal |
| 15792 | Chemical peel, nonfacial; epidermal |
| 15793 | Chemical peel, nonfacial; dermal |
| 15820 | Blepharoplasty, lower eyelid; |
| 15821 | Blepharoplasty, lower eyelid; with extensive herniated fat pad |
| 15822 | Blepharoplasty, upper eyelid; |
| 15823 | Blepharoplasty, upper eyelid; with excessive skin weighting down lid |
# PAYMENT POLICY
# COSMETIC PROCEDURES

| CPT/HCPCS Code | Descriptor |
|---------------|------------|
| 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, infraumbilical 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 |
| 17380 | Electrolysis epilation, each 30 minutes |
| 19316 | Mastopexy |
| 19318 | Reduction mammoplasty |
| 19325 | Mammaplasty, augmentation; with prosthetic implant |
| 19340 | Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction |
| 19342 | Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction |
# PAYMENT POLICY
# COSMETIC PROCEDURES

| CPT/HCPCS Code | Descriptor |
|---------------|------------|
| 19355 | Correction of inverted nipples |
| 19380 | Revision of reconstructed breast |
| 21120 | Genioplasty; augmentation (autograft, allograft, prosthetic material) |
| 21121 | Genioplasty; sliding osteotomy, single piece |
| 21122 | Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin) |
| 21123 | Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) |
| 21125 | Augmentation, mandibular body, or angle; prosthetic material |
| 21127 | Augmentation, mandibular body, or angle; with bone graft, onlay or interpositional (includes obtaining autograft) |
| 21137 | Reduction forehead; contouring only |
| 21138 | Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) |
| 21139 | Reduction forehead; contouring and setback of anterior frontal sinus wall |
| 21141 | Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft |
| 21142 | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft |
| 21143 | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft |
| 21145 | Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) |
| 21146 | Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft) |
| 21147 | Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies) |
| 21150 | Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome) |
| 21151 | Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts) |
| 21154 | Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I |
| 21155 | Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I |
| 21159 | Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I |
| 21160 | Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I |
# PAYMENT POLICY
# COSMETIC PROCEDURES

| CPT/HCPCS Code | Descriptor |
|---------------|------------|
| 21196 | Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation |
| 21199 | Osteotomy, mandible, segmental; with genioglossus advancement |
| 21208 | Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) |
| 21209 | Osteoplasty, facial bones; reduction |
| 21248 | Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial |
| 21249 | Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete |
| 21270 | Malar augmentation, prosthetic material |
| 21280 | Medial canthopexy (separate procedure) |
| 21282 | Lateral canthopexy |
| 21295 | Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approach |
| 21296 | Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach |
| 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 |
| 30120 | Excision or surgical planing of skin of nose for rhinophyma |
| 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) |
| 30465 | Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction) |
| 36468 | Single or multiple injections of sclerosing solutions, spider veins (telangiectasia), limb or trunk |
| 36470 | Injection of sclerosing solution; single vein |
| 36471 | Injection of sclerosing solution; multiple veins, same leg |
| 40500 | Vermilionectomy (lip shave), with mucosal advancement |
| 43770 | Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components) |
# PAYMENT POLICY
# COSMETIC PROCEDURES

| CPT/HCPCS Code | Descriptor |
|---------------|------------|
| 43771 | Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only |
| 43772 | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only |
| 43773 | Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only |
| 43774 | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components |
| 65760 | Keratomileusis |
| 65765 | Keratophakia |
| 65767 | Epikeratoplasty |
| 67900 | Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) |
| 67901 | Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) |
| 67902 | Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia) |
| 67903 | Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach |
| 67904 | Repair of blepharoptosis; (tarso) levator resection or advancement, external approach |
| 67906 | Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) |
| 67908 | Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanela-Servat type) |
| 67950 | Canthoplasty (reconstruction of canthus) |
| 69090 | Ear piercing |
| 69300 | Otoplasty, protruding ear, with or without size reduction |
| L8600 | Implantable breast prosthesis, silicone or equal |
| L8699 | Prosthetic implant, not otherwise specified |


# PAYMENT POLICY
# COSMETIC PROCEDURES

## Revision History
| Date       | Description |
|------------|-------------|
| 05/09/2017 | Converted to the new template and conducted review. |
| 06/20/2018 | Conducted annual review |
| 09/01/2019 | Conducted review |
| 11/01/2019 | Annual Review completed |
| 11/01/2020 | Annual Review completed |
| 11/30/2021 | Annual Review completed; no major updates required |
| 12/01/2022 | Annual Review completed; no major updates required |
| 11/13/2023 | Retired 49560 and 49565 and add the updated codes |
| 1/17/2025  | Annual Review completed; Updated links for References to include LCDs and CMS Policies; Removed CPTs 49592, 49593, 49595, 49613, 49614, 49615, 49617 from policy. |
| 11/05/2025 | Annual Review Completed, validated policy content, references and links, added revision date, and removed deleted codes 15819 and 19324 |

## Important Reminder
For the purposes of this payment policy, “Health Plan” means a health plan that has adopted this payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any other of such health plan’s affiliates, as applicable.

The purpose of this payment policy is to provide a guide to payment, which is a component of the guidelines used to assist in making coverage and payment determinations and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage and payment determinations and the administration of benefits are subject to all terms, conditions, exclusions, and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable plan-level administrative policies and procedures.

This payment policy is effective as of the date determined by Health Plan. The date of posting may not be the effective date of this payment policy. This payment policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this payment policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. Health Plan retains the right to change, amend or withdraw this payment policy, and additional payment policies may be developed and adopted as needed, at any time.

This payment policy does not constitute medical advice, medical treatment, or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care and are solely responsible for the medical advice and treatment of members. This payment policy is not intended to recommend treatment for members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this policy are independent contractors who exercise independent judgment and over whom Health Plan has no control or right of control. Providers are not agents or employees of Health Plan. This payment policy is the property of Centene Corporation.
# PAYMENT POLICY
# COSMETIC PROCEDURES

Unauthorized copying, use, and distribution of this payment policy or any information contained herein are strictly prohibited. Providers, members, and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services.

**Note:** For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this payment policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this payment policy.

**Note:** For Medicare members, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs and LCDs should be reviewed prior to applying the criteria set forth in this payment policy. Refer to the CMS website at http://www.cms.gov for additional information.

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