Oscar Commercial Clinical Policy

Oscar Medications for Cosmetic Purposes (PG080) Form


Effective Date

11/05/2020

Last Reviewed

12/14/2022

Original Document

  Reference



The integumentary system consists of the skin, hair, and nails. Many conditions of the integumentary system are benign (non-malignant) and cause no functional limitation. While many conditions require no intervention, some cases may necessitate intervention due to bothersome symptoms and/or functional limitations. However, when treatment is sought for a lesion or scar that does not cause a functional limitation or bothersome symptom(s), the treatment is considered cosmetic. Medications used with the intent to improve the appearance of a body part are considered cosmetic and are, thus, excluded from coverage.

Definitions

Cosmetic refers to a procedure or medication used to enhance or alter human anatomy/appearance in a non-natural form or to repair a perceived "defect" that is within the normal variation of anatomical form.1

Functional Limitation refers to a restriction or lack of ability to perform an action or activity in the manner or within the range considered normal that results from a physical or medical condition.

Integumentary system refers to the set of organs that form the external covering of the body and protects it from infection, abrasion, loss of moisture, and damage from the environment.

Lesion is a nonspecific term that refers to any structural change in the body.

Scar is a mark left by a healed wound, sore, or burn.

Experimental or Investigational / Not Medically Necessary

The Plan considers medications used for certain purposes as not medically necessary. These include:

  • Products used on skin, hair, nail lesions, or scars solely for cosmetic reasons without a functional limitation.
  • Products used solely to improve physical appearance.

Examples of cosmetic uses that are deemed not medically necessary include:

  • Hair loss treatment (except for alopecia areata)
  • Baldness treatment (male and female)
  • Chemical peels
  • Dermal fillers
  • Hair removal or replacement
  • Skin lightening/darkening treatments (e.g., melasma, vitiligo)
  • Scar removal or revision
  • Skin abrasion, exfoliation, or resurfacing
  • Skin tag removal
  • Wrinkles treatment
References
  1. American Academy of Dermatology. Cosmetic Treatments. Available at: https://www.aad.org/public/cosmetic. Accessed October 21, 2020.
  2. Carruthers J, Humphrey S. Injectable soft tissue fillers: Overview of clinical use. Dover, JS, Butler, CE (Eds), UpToDate, Waltham, MA. Available at: www.Uptodate.com. Accessed October 21, 2020.
  3. Goldstein BG. Overview of benign lesions of the skin. Dellavalle RP (Ed), UpToDate, Waltham, MA. Available at: www.Uptodate.com. Accessed October 21, 2020.
  4. Phillips TG, Slomiany, WP, Allison R. Hair Loss: Common Causes and Treatment. Am Fam Physician 2017; 96(6): 371-378.
  5. Plensdorf S, Livieratos M, Dada N. Pigmentation Disorders: Diagnosis and Management. Am Fam Physician 2017; 96 (12): 797-804.
  6. Rich P. Overview of Nail Disorders. Stratman E (Ed), UpToDate, Waltham, MA. Available at: www.Uptodate.com. Accessed October 21, 2020.
  7. Small MD. Botulinum Toxin Injection for Facial Wrinkles. Am Fam Physician 2014; 90(3):168-175.
  8. Tully AS, Trayes KP. Evaluation of Nail Abnormalities. Am Fam Physician 2012: 85(8); 779-787.

Clinical Guideline Revision / History Information

  • Original Date: 11/05/2020
  • Reviewed/Revised: 12/01/2021, 09/15/2022, 12/08/2022, 12/14/2023
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