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HumanaCommercial Clinical Policy

Humana Cosmetic and Reconstructive Surgery Form


Notes: State mandates or individual certificate coverage for cosmetic or gender affirmation surgery may modify eligibility.

Indications

(722928) Is the reconstructive surgery due to bodily injury, congenital disease or anomaly, or infection or other disease of the involved part? 
(722929) Is there a functional impairment present? 

Contraindications

(722930) Is the reconstructive surgery solely for cosmetic purposes to improve or change appearance or self-esteem? 
(722931) Is the reconstructive surgery following an elective cosmetic procedure? 
(722932) Is the procedure experimental or investigational as not widely accepted in nationally recognized peer-reviewed medical literature? 
YesNoN/A
YesNoN/A
YesNoN/A

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Effective Date

10/10/2023

Last Reviewed

NA

Original Document

  Reference



Cosmetic and Reconstructive Surgery

Medical Coverage Policy

Effective Date: 10/10/2023
Revision Date: 10/10/2023
Review Date: 08/24/2023
Policy Number: HUM-0345-048

Change Summary:

Updated Coverage Limitations, Background, References

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

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