Cosmetic Procedures, Treatment Form

MEDICAL COVERAGE POLICY SERVICE: Cosmetic Procedures and Treatment Policy Number: 263 Effective Date: 11/01/2025 Last Review: 08/11/2025 Next Review: 08/11/2026 Page 1 of 7 Important note: Unless otherwise indicated, medical policies will apply to all lines of business. Medical necessity as defined by this policy does not ensure the benefit is covered. This medical policy does not replace existing federal or state rules and regulations for the applicable service or supply. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan documents. See the member plan specific benefit plan document for a complete description of plan benefits, exclusions, limitations, and conditions of coverage. In the event of a discrepancy, the plan document always supersedes the information in this policy. SERVICE: Cosmetic Procedures and Treatment PRIOR AUTHORIZATION: Certain Procedures Require Prior Authorization. POLICY:
BSWHP plans exclude coverage of cosmetic surgery that is not medically necessary but may provide coverage when the surgery is needed to improve the functioning of a body part, or is otherwise medically necessary, even if the surgery also improves or changes the appearance of a portion of the body. Additionally, many BSWHP plans specify that certain procedures are not considered to be cosmetic surgery (e.g., surgery to correct the result of injury, post-mastectomy breast reconstruction, surgery needed to treat certain congenital defects such as cleft lip or cleft palate). Please check benefit plan descriptions for details. This policy supplements plan coverage language by listing some procedures that are always considered cosmetic, and those that may be medically necessary despite cosmetic aspects. Please note that, while this policy addresses many common procedures, it does not address ALL procedures that might be considered to be cosmetic and thus excluded from coverage. BSWHP reserves the right to deny coverage for other procedures that are cosmetic and not medically necessary. Note: Unless otherwise indicated (see below), this policy will apply to all lines of business. For Medicare plans, please refer to appropriate Medicare NCD (National Coverage Determination) or LCD (Local Coverage Determination). If there are no applicable NCD or LCD criteria, use the criteria set forth below. L35004 Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow L35090 Cosmetic and Reconstructive Surgery A56587 Billing and Coding: Cosmetic and Reconstructive Surgery L34938 Removal of Benign Skin Lesions For Medicaid plans, please confirm coverage as outlined in the Texas Medicaid Provider Procedures Manual | TMHP (TMPPM). If there are no applicable criteria to guide medical necessity decision making in the TMPPM, use the criteria set forth below. The following procedures are primarily for altering and/or enhancing appearance in the absence of documented impairment of physical function, and thus are considered cosmetic:

MEDICAL COVERAGE POLICY SERVICE: Cosmetic Procedures and Treatment Policy Number: 263 Effective Date: 10/01/2025 Last Review: 08/11/2025 Next Review: 08/11/2026 Page 2 of 7  Aesthetic alteration of the female genitalia (e.g., hymenoplasty, inverted V hoodoplasty, labiaplasty, and mons pubis-pexy)  Aesthetic operations on umbilicus  Breast augmentation (breast implants and pectoral implants) unless required under Women’s Health and Cancer Rights Act (WHCRA)  Breast lift (mastopexy)  Buttock lift or augmentation  Cheek implant (malar implant/augmentation)  Chin implant (genioplasty, mentoplasty)  Correction of diastasis recti abdominis  Correction of inverted nipple, unless related to cancer surgery.  Ear or body piercing  Electrolysis or laser hair removal  Excision of excessive skin of thigh (thigh lift, thighplasty), leg, hip, buttock, arm (arm lift, brachioplasty), forearm or hand, submental fat pad, or other areas  Intense pulsed light laser for facial redness  Lacrimal gland resuspension for lacrimal gland prolapse  Mesotherapy (injection of various substances into the tissue beneath the skin to sculpt body contours by lysing subcutaneous fat)  Neck Tucks  Removal of frown lines  Removal of spider angiomata  Removal of supernumerary nipples (polymastia)  Salabrasion  Selective neurectomy of the gastrocnemius muscle for correction of calf hypertrophy  Surgery for body dysmorphic disorder  Surgery to correct moon face  Surgery to correct tuberous breast deformity  Surgical depigmentation (e.g., laser treatment) of nevus of Ito or Ota  Tattoo removal  Treatment with small gel-particle hyaluronic acid (e.g., Restylane) and large gel-particle hyaluronic acid (e.g., Perlane) to improve the skin’s contour and/or reduce depressions due to acne, injury, scars, or wrinkles  Vaginal rejuvenation procedures (clitoral reduction, designer vaginoplasty, hymenoplasty, re- virgination, G-spot amplification, pubic liposuction or lift, reduction of labia minora, labia majora surgery/reshaping, thermal therapy (e.g., radiofrequency (ThermiVa and Viveve procedures) and laser) and vaginal tightening, not an all-inclusive list) The following procedures may be considered medically necessary when criteria are met (The requesting physicians may be required to submit documentation, including photographs, letters documenting medical necessity, chart records, etc.):

MEDICAL COVERAGE POLICY SERVICE: Cosmetic Procedures and Treatment Policy Number: 263 Effective Date: 10/01/2025 Last Review: 08/11/2025 Next Review: 08/11/2026 Page 3 of 7 Procedure Criteria / Reference Code(s) Abdominoplasty - May be considered medically necessary when surgery is performed to alleviate such complicating factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertriginous dermatitis. L35090 15847 InterQual L35004 15820 15821 15822 15823 Blepharoplasty - May be considered medically necessary when criteria are met. Breast reduction - May be considered medically necessary when criteria are Med Policy 209 L35090 19318 met. Chemical peels (chemical exfoliation) - May be considered medically necessary when:  The member has actinic keratoses OR other pre-malignant skin lesions, AND  The member has 15 or more lesions, AND  The member has tried treatment with topical 5-fluorouracil (5-FU) or imiquimod OR it is contraindicated Listed Criteria 15788 15789 15792 15793 Dermabrasion - May be considered medically necessary when correcting defects resulting from traumatic injury, surgery or disease or for the treatment of rhinophyma, OR:  The member has superficial basal cell carcinomas OR pre-cancerous actinic keratoses, AND  Conventional methods of removal such as cryotherapy, curettage, and excision, are impractical due to the number and distribution of the lesions, AND  The member has failed a trial of 5-fluorouracil (5-FU) (Efudex) or imiquimod (Aldara) OR it is contraindicated Listed Criteria L35090 15780 15781 15782 15783 15786 Dermal and subcutaneous injections of filling material - May be medically necessary as part of breast reconstruction following breast cancer surgery. Dermal injections - May be considered medically necessary for members with HIV having facial lipodystrophy syndrome due to antiretroviral therapy, AND the fillers being used are FDA approved (e.g., poly-L-lactic acid dermal injection (Sculptra) or calcium hydroxylapatite dermal injection (Radiesse)) Listed Criteria 11950 11951 11952 11954 G0429 Genioplasty (chin augmentation/implantation)-Whether performed alone or in conjunction with other orthognathic surgical procedures is considered cosmetic. See Policy 064 Gender Affirming Care for Exception 21120 21121 21122 21123

MEDICAL COVERAGE POLICY SERVICE: Cosmetic Procedures and Treatment Policy Number: 263 Effective Date: 10/01/2025 Last Review: 08/11/2025 Next Review: 08/11/2026 Page 4 of 7 Hair removal - May be considered medically necessary for one of the following:  Recurrent infected cyst  Hair follicle infections  After surgical treatment of pilonidal sinus disease Listed Criteria 17380 Maxillofacial In general, these may be considered cosmetic and are not a benefit except when the procedure is performed as a result of trauma or injury for the purpose of:
 Reconstructing tissues/body structures  Repairing damaged tissues See listed criteria 21082 21083 21087 21088 21089 Keloids- Repair of keloids may be considered medically necessary if they cause pain or a functional limitation. Med Policy 099 Lipomas - Excision may be considered medically necessary if lipomas are tender and inhibit the member's ability to perform daily activities due to the lipoma's location on body parts that are subject to regular touch or pressure. All other indications for lipectomy are considered cosmetic and thus not a covered benefit. Listed Criteria 15876 15877 15878 15879 Mandible Augmentation InterQual 21125 21127 Orthognathic Surgery
Orthognathic surgery is considered cosmetic when performed in the absence of significant functional impairment, including but not limited to: • When used for altering or improving bite; or • When performed solely for the purpose of improving/altering appearance InterQual 21193 21194 21198 21199 21206 21208 21210 21215 Otoplasty - May be considered medically necessary when being performed to improve hearing by directing sound in the ear canal due to ears being absent or deformed from trauma, surgery, disease, or congenital defect. Otoplasty to correct large or protruding ears (bat ears) is considered cosmetic when the surgery will not improve hearing. Listed Criteria 69300 Panniculectomy - May be considered medically necessary when criteria are InterQual L35090 15830 met. Panniculectomy is NOT covered when performed as an adjunct to other medically necessary procedures (e.g., hysterectomy, ventral/incisional hernia repair) unless the criteria for panniculectomy are independently met.

MEDICAL COVERAGE POLICY SERVICE: Cosmetic Procedures and Treatment Policy Number: 263 Effective Date: 10/01/2025 Last Review: 08/11/2025 Next Review: 08/11/2026 Page 5 of 7 Laser Treatment - May be considered medically necessary when criteria are met. Med Policy 099 L34938 17106 17107 17108 Reconstructive Surgeries Involving Bones of the Skull and Face may be considered medically necessary when there is a functional impairment that cannot be corrected without surgery Listed Criteria 21175 21183 Rhinoplasty
May be considered medically necessary when nasal surgery is performed to improve nasal respiratory function, correct anatomic abnormalities caused by birth defects or disease, or revise structural deformities produced by trauma, the procedure is considered reconstructive. InterQual L38914 30400 30410 30420 30430 30435 30450 30460 Rhytidectomy - may be considered medically necessary when there is functional impairment that cannot be corrected without surgery. Listed Criteria 15824 15825 15826 15828 15829 Scar revision - Repair of scars that result from surgery may be considered medically necessary if they cause symptoms or functional impairment. Listed Criteria 15786 Skin tag removal - may be considered medically necessary for recurrent bleeding. Listed Criteria 11200 11201 Tattoo - May be considered medically necessary in conjunction with reconstructive breast surgery post-mastectomy, and for marking for radiation therapy. 11920 11921 11922 Listed Criteria True incisional or ventral hernia repair (not diastasis recti) Medically Necessary BACKGROUND / DEFINITIONS: Abdominoplasty - A surgical procedure which includes the excision of skin and subcutaneous fat in the abdomen, and a range of secondary nonfunctional procedures (e.g., transposition of the umbilicus, repair of lax abdominal muscles and suction assisted liposuction). The procedure is also referred to as a “tummy tuck” because it produces a flatter, firmer, tighter stomach and thin waist and provides an overall improvement in the person’s shape and figure. Panniculectomy and abdominoplasty are often performed together to achieve the best cosmetic result, but abdominoplasty is an add-on procedure that is not covered. Intertrigo - An inflammation of the body folds, most often due to chafing together of warm, moist skin, and usually located in the inner thighs, armpits, and underside of the breasts or belly. Most common in those who are overweight or diabetic, intertrigo is red and raw looking, and may itch, ooze or be sore;

MEDICAL COVERAGE POLICY SERVICE: Cosmetic Procedures and Treatment Policy Number: 263 Effective Date: 10/01/2025 Last Review: 08/11/2025 Next Review: 08/11/2026 Page 6 of 7 infection with bacteria or yeast may develop in the broken skin. Lipectomy - A surgical technique that is used to cut and remove unwanted fat deposits from specific areas of the body. It is not a substitute for weight reduction but is a method of removing localized fat that does not respond to dieting and exercise. A lipectomy may be done for cosmetic reasons or to treat functional impairment. Panniculectomy - Surgical excision of redundant (excess) hanging abdominal skin and fat (panniculus, pannus, apron), not including muscle plication or neoumbilicoplasty as in an abdominoplasty. The most common indication is the patient who develops redundant tissue following significant weight loss. There is a risk of complications when this tissue reaches a certain size—such as intertriginous dermatitis, cellulitis, skin ulceration, impaired mobility and interference with ADLs. According to the American Society of Plastic Surgeons (ASPS), the severity of abdominal deformities is graded as follows:  Grade 1: Panniculus covers hairline and mons pubis but not the genitals  Grade 2: Panniculus covers genitals and upper thigh crease  Grade 3: Panniculus covers upper thigh  Grade 4: Panniculus covers mid-thigh  Grade 5: Panniculus reaches the knees and below Panniculitis - Intertriginous rashes, ulcerations, and/or infections that develop in the abdominopelvic fold. Physical Functional Impairment - A condition in which the normal or proper action of a body part is damaged and affects the ability to participate in activities of daily living. Physical functional impairments include, but are not limited to, problems with ambulation, communication, respiration, swallowing, vision, or skin integrity. A physical functional impairment may impact an individual’s emotional well- being or mental health, but such impact is not considered in determining whether or not a physical functional impairment exists. CODES: Important note: Due to the wide range of applicable diagnosis codes and potential changes to codes, an inclusive list may not be presented, but the following codes may apply. Inclusion of a code in this section does not guarantee that it will be reimbursed, and patient must meet the criteria set forth in the policy language. CPT Codes See table above CPT Not Covered See table above ICD10 codes See table above ICD10 Not covered See table above POLICY HISTORY:

MEDICAL COVERAGE POLICY SERVICE: Cosmetic Procedures and Treatment Policy Number: 263 Effective Date: 10/01/2025 Last Review: 08/11/2025 Next Review: 08/11/2026 Page 7 of 7 Status Date Action New 04/22/2020 New policy Reviewed 05/27/2021 No changes Reviewed 05/26/2022 No changes Reviewed 07/27/2023 Clarified and updated information Reviewed 05/13/2024 Formatting changes, added hyperlinks to CMS and TMPPM resources, beginning and ending note sections updated to align with CMS requirements and business entity changes. Added “BACKGROUND / DEFINITIONS” section. Added language and references for Panniculectomy from retired Medical Policy 083 – Panniculectomy. Reviewed 03/10/2025 Removed reference to a retired policy; Added 15792, 15793 to Chemical Peels ending note section updated to align with business entity changes. Reviewed 08/11/2025 Removed “Medicare NCD or LCD specific InterQual criteria may be used when available.” Added the following procedures with their respective CPT codes to the table along with guidance: Genioplasty (21120, 21121, 21122, 21123), Maxillofacial procedures (21082, 21083, 21087, 21088, 21089), mandible augmentation (21125, 21127), orthognathic surgery (21193, 21194, 21198, 21199, 21206, 21208, 21210, 21215), Reconstructive Surgeries Involving Bones of the Skull and Face (21175 and 21183) and rhinoplasty (30400, 30410, 30420, 30430, 30435, 30450, 30460) REFERENCES: The following scientific references were utilized in the formulation of this medical policy. BSWHP will continue to review clinical evidence related to this policy and may modify it at a later date based upon the evolution of the published clinical evidence. Should additional scientific studies become available, and they are not included in the list, please forward the reference(s) to BSWHP so the information can be reviewed by the Medical Coverage Policy Committee (MCPC) and the Quality Improvement Committee (QIC) to determine if a modification of the policy is in order.

1. American Society of Plastic Surgeons Recommended Insurance Coverage Criteria for Third Party Payers-Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients
2. Ramirez OM. Abdominoplasty and abdominal wall rehabilitation: A comprehensive approach. Plast Reconstr Surg. 2000;105(1):425-435.
3. Elbaz JS, Flageul G, Olivier-Masveyraud F. 'Classical' abdominoplasty. Ann Chir Plast Esthet. 1999;44(4):443461.
4. Vastine VL, Morgan RF, Williams GS, et al. Wound complications of abdominoplasty in obese patients. Ann Plast Surg. 1999;42(1):34-39.
5. Cardenas-Camarena L, Gonzalez LE. Large-volume liposuction and extensive abdominoplasty: A feasible alternative for improving body shape. Plast Reconstr Surg. 1998;102(5):1698-1707.Aly AS, Cram AE, Chao M, et al. Belt lipectomy for

MEDICAL COVERAGE POLICY SERVICE: Cosmetic Procedures and Treatment Policy Number: 263 Effective Date: 10/01/2025 Last Review: 08/11/2025 Next Review: 08/11/2026 Page 8 of 7 circumferential truncal excess: The University of Iowa experience. Plast Reconstr Surg. 2003;111(1):398-413.

6. Golladay ES. Abdominal hernias. eMedicine General Surgery Topic 2703. Omaha, NE: eMedicine.com; updated July 9,
7. Available at: http://www.emedicine.com/med/topic2703.htm Accessed April 22, 2004.
8. State of Minnesota, Health Technology Advisory Committee. Tumescent liposuction. Technology Assessment. St. Paul, MN: HTAC; 2002.
9. Cooter R, Robinson D, Babidge W, et al. Systematic review of ultrasound-assisted lipoplasty: Update and reappraisal. ASERNIP-S Report No. 17. North Adelaide, SA: Royal Australasian College of Surgeons, Australian Safety and Efficacy Register of New Interventional Procedures -Surgical (ASERNIP- S); 2002.
10. Patterson J. Outcomes of abdominoplasty. STEER: Succint and Timely Evaluated Evidence Reviews. Bazian Ltd., eds. London, UK: Wessex Institute for Health Research and Development, University of Southampton; 2003; 3(2):1-9.
11. Bragg TW, Jose RM, Srivastava S. Patient satisfaction following abdominoplasty: An NHS experience. J Plast Reconstr Aesthet Surg. 2007;60(1):75-78.
12. Graf R, de Araujo LR, Rippel R, et al. Lipoabdominoplasty: Liposuction with reduced undermining and traditional abdominal skin flap resection. Aesthetic Plast Surg. 2006;30(1):1-8.
13. Vila-Rovira R. Lipoabdominoplasty. Clin Plast Surg. 2008;35(1):95-104; discussion 105.
14. Heller JB, Teng E, Knoll BI, Persing J. Outcome analysis of combined lipoabdominoplasty versus conventional abdominoplasty. Plast Reconstr Surg. 2008;121(5):1821-1829.
15. Halbesma GJ, van der Lei B. The reverse abdominoplasty: A report of seven cases and a review of English-language literature. Ann Plast Surg. 2008;61(2):133-137.
16. A. Graf, K. Yang, K. Klement, N. Kim, H. Matloub. Abdominal suspension during massive panniculectomy: A novel technique and review of the literature. JPRAS Open. June 2016. https://doi.org/10.1016/j.jpra.2016.04.001. Accessed 18, September 2016.
17. Vincenzo Colabianchi, Giancarlo de Bernardinis, Matteo Giovannini, and Marika Langella, Panniculectomy Combined with Bariatric Surgery by Laparotomy: An Analysis of 325 Cases, Surgery Research and Practice, vol. 2015, Article ID 193670, 10 pages, 2015. doi:10.1155/2015/193670. Accessed 18 September 2017
18. ASPS Executive Committee: June 2017. American Society of Plastic Surgeons Practice Parameter for Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients. Note: Health Maintenance Organization (HMO) products are offered through Scott and White Health Plan dba Baylor Scott & White Health Plan, and Scott & White Care Plans dba Baylor Scott & White Care Plan. Insured PPO and EPO products are offered through Baylor Scott & White Insurance Company. Scott and White Health Plan dba Baylor Scott & White Health Plan serves as a third-party administrator for self-funded employer-sponsored plans. Baylor Scott & White Care Plan and Baylor Scott & White Insurance Company are wholly owned subsidiaries of Scott and White Health Plan. These companies are referred to collectively in this document as Baylor Scott & White Health Plan. RightCare STAR Medicaid is offered through Scott and White Health Plan in the Central Texas Medicaid Rural Service Area (MRSA); FirstCare STAR is offered through SHA LLC dba FirstCare Health Plans (FirstCare) in the Lubbock and West MRSAs;and FirstCare, CHIP is offered through FirstCare in the Lubbock Service Area.