Cosmetic Services/Procedures Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699
MEDICAL COVERAGE POLICY | 1
(401) 274-4848 WWW.BCBSRI.COM

OVERVIEW
This policy was written to document the services that are considered cosmetic. Cosmetic procedures are performed primarily to refine or reshape body structures that are not functionally impaired, to improve appearance or self-esteem, or for other psychological, psychiatric, or emotional reasons. For services that could possibly be considered not cosmetic, refer to the individual policies listed in the Related Policies section. For services that could possibly be considered cosmetic the list below may vary between groups and contracts, please refer to the member’s individual Benefit Booklet, Evidence of Coverage or Subscriber Agreement for a complete listing.

MEDICAL CRITERIA
Not applicable

PRIOR AUTHORIZATION
Not applicable

POLICY STATEMENT
Medicare Advantage Plans Cosmetic services are not covered under Medicare Advantage Plans because they are not determined to be reasonable and necessary.
Commercial Products
The following procedures are contract exclusions as these are considered cosmetic:
• Abdominoplasty
• Brow ptosis surgery
• Cervicoplasty
• Chemical exfoliations, peels, abrasions (or dermabrasions or planning for acne, scarring, wrinkling, sun damage, or other benign conditions)
• Correction of variations in normal anatomy including augmentation mammoplasty and correction of congenital breast asymmetry
• Dermabrasion
• Ear Piercing or repair of a torn earlobe
• Excision of excess skin or subcutaneous tissue (except panniculectomy as listed above)
• Genioplasty
• Hair transplants
• Hair removal (including electrolysis epilation)
• Inverted nipple surgery
• Laser treatment for acne and acne scars;
• Osteoplasty: Facial bone reduction
• Otoplasty
• Procedures to correct visual acuity including, but not limited to, cornea surgery or lens implants

EFFECTIVE DATE: 01|01|2024
POLICY LAST UPDATED: |04|2023 10 Medical Coverage Policy | Cosmetic Services/Procedures

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699
MEDICAL COVERAGE POLICY | 2
(401) 274-4848 WWW.BCBSRI.COM

• Removal of asymptomatic benign skin lesions
• Repeated cauterizations or electrofulguration methods used to remove growths on the skin
• Rhinoplasty
• Rhytidectomy
• Scar revision, regardless of symptoms
• Sclerotherapy for spider veins
• Skin tag removal
• Subcutaneous injection of filling material
• Suction-assisted lipectomy
• Tattooing or tattoo removal (except tattooing of the nipple/areola related to a mastectomy)
• Treatment of vitiligo

For coverage of procedures done in conjunction with a non-covered service, please refer to the following policy: Coverage of Complications Following a Non-covered Procedure.

COVERAGE
Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable not covered benefits/coverage.

BACKGROUND
Medicare Advantage Plans Cosmetic surgery, or expenses incurred in connection with such surgery, is not covered. Cosmetic surgery includes any 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 improvement of the functioning of a malformed body member. For example, this exclusion does not apply to surgery in connection with treatment of severe burns or repair of the face following a serious automobile accident, or to surgery for therapeutic purposes, which coincidentally also serves some cosmetic purpose.

Commercial Products
Cosmetic procedures are performed primarily to refine or reshape body structures that are not functionally impaired, to improve appearance or self-esteem, or for other psychological, psychiatric, or emotional reasons. Although cosmetic procedures are not covered, procedures may be covered if they meet the criteria outlined in the individual medical policies.

Medical and hospital services are sometimes required to treat a condition that arises as a result of services that are not covered because they are determined to be not reasonable and necessary or because they are excluded from coverage for other reasons.

CODING
Please refer to individual medical policies for coding information.

RELATED POLICIES
Abdominoplasty & Panniculectomy, Preauthorization via the Web-Based Tool for Procedures
Blepharoplasty, Preauthorization via the Web-Based Tool for Procedures
Bariatric Surgery, Preauthorization via the Web-Based Tool for Procedures
Breast Implant Removal, Preauthorization via the Web-Based Tool for Procedures
Breast Reconstruction Mandate, Preauthorization via the Web-Based Tool for Procedures
Coverage of Complications after a Non-covered Procedure Gender Affirming Care

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699
MEDICAL COVERAGE POLICY | 3
(401) 274-4848 WWW.BCBSRI.COM

Laser Treatment for Proliferative Vascular Lesions: Preauthorization via the Web-Based Tool for Procedures
Mastectomy for Gynecomastia: Preauthorization via the Web-Based Tool for Procedures
Orthognathic Surgery, Preauthorization via the Web-Based Tool for Procedures
Rhinoplasty with Nasal Reconstruction, Preauthorization via the Web-Based Tool for Procedures
Reduction Mammaplasty, Preauthorization via the Web-Based Tool for Procedures
Varicose Vein Treatments, Preauthorization via the Web-Based Tool for Procedures

PUBLISHED
Provider Update, December 2023 Provider Update, June 2021
Provider Update, June 2019
Provider Update, February 2018
Provider Update, April 2017
Provider Update, June 2016

REFERENCES:
Medicare Benefit Policy Manual, chapter 16- General Exclusions From Coverage
MLN: Items and Services That Are Not Covered Under the Medicare Program

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.