![]() ![]() ![]() Note: For repair of keloids that do not cause pain or functional impairment, exceptions to cosmetic surgery exclusion may apply. Repair of keloids is considered medically necessary if they cause pain or a functional limitation the need for repeated cautery of bleeding telangiectasias or frequent courses of antibiotics for pustular eruptions)Įxcision or shaving of rhinophyma is considered cosmetic when the afore-mentioned criteria are not met Excision or shaving of rhinophyma for the treatment of bleeding or infection refractory to medical therapy.Repair (e.g., tear) of a traumatic injury is considered medically necessary Įarlobe repair to close a stretched pierce hole, in the absence of a traumatic injury, is considered cosmetic Retreatments with FDA-approved fillers are considered medically necessary for facial lipodystrophy syndrome due to antiretroviral therapy in HIV-infected persons (e.g., poly-L-lactic acid dermal injection (Sculptra) or calcium hydroxylapatite dermal injection (Radiesse) for HIV lipoatrophy)Ĭonsidered medically necessary for treating facial lipodystrophy syndrome due to antiretroviral therapy in HIV-infected persons considered cosmetic for all other indications Dermal injections of Food and Drug Administration (FDA)-approved fillers.The requesting physicians may be required to submit documentation, including photographs, letters documenting medical necessity, chart records, etc.Ĭonsidered medically necessary when criteria in CPB 0084 - Eyelid Surgery, are met Ĭonsidered medically necessary when criteria in CPB 0017 - Breast Reduction Surgery and Gynecomastia Surgery or CPB 0615 - Gender Affirming Surgery, are met Ĭonsidered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne Surgery are met Ĭonsidered cosmetic except as a treatment for urinary incontinence when medical necessity criteria in CPB 0223 - Urinary Incontinence are met Ĭonsidered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peel, and Acne Surgery are met The following surgeries and procedures are considered medically necessary when criteria are met. Aetna reserves the right to deny coverage for other procedures that are cosmetic and not medically necessary. ![]() Please note that, while this policy statement addresses many common procedures, it does not address all procedures that might be considered to be cosmetic surgery excluded from coverage. ![]() This policy statement supplements plan coverage language by identifying procedures that Aetna considers medically necessary despite cosmetic aspects, and other cosmetic procedures that Aetna considers not medically necessary. Please check benefit plan descriptions for details. Additionally, many Aetna plans specify that certain surgeries are not considered to be cosmetic (e.g., surgery to correct the result of injury, post-mastectomy breast reconstruction, breast augmentation to treat gender dysphoria, surgery needed to treat certain congenital defects such as cleft lip or cleft palate). IntroductionĪetna plans exclude coverage of cosmetic surgery and procedures that are not medically necessary, but generally provide coverage when the surgery or procedure is needed to improve the functioning of a body part or otherwise medically necessary even if the surgery or procedure also improves or changes the appearance of a portion of the body. This Clinical Policy Bulletin addresses cosmetic surgery and procedures. Number: 0031 Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References ![]()
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