The following procedures may be considered reconstructive or cosmetic. Cosmetic procedures and/or surgery are statutorily excluded by Medicare. These services will be denied as non-covered. Non-covered procedures do not need to be billed to the Contractor.
Cosmetic surgery can be defined as a procedure that is performed to reshape normal structures of the body in order to improve the patient’s appearance and self-esteem. These procedures can be performed for medically necessary or cosmetic reasons.
1. Reduction Mammoplasty (CPT 19318) This procedure will be denied when performed for a cosmetic reason (V50.1).
2. Mastectomy for gynecomastia (19300): If the tissue removed is primarily fatty tissue, the surgery is classified as cosmetic (V50.1) and will be denied as non-covered.
3. Punch graft hair transplant (CPT 15775-15776) To indicate this procedure is performed for cosmetic reasons, use (V50.0) hair transplant to receive a non-covered denial.
4. Rhinoplasty (CPT codes 30400-30450) When nasal surgery is performed solely to improve the patient’s appearance in the absence of any signs and/or symptoms of functional abnormalities, it is considered cosmetic (V50.1) and will be denied as non-covered.
5. Excision, excessive skin and subcutaneous tissue (including lipectomy); abdomen (abdominoplasty) (15830) is not covered when performed to improve the patient’s appearance (V50.1).
6. Chemical Peel (15788-15793) For cosmetic reasons (V50.1) will be denied as not covered
7. Dermabrasion, segmental, face (15781) performed for a cosmetic reason (V50.1) will be denied as non-covered.
8. Rhytidectomy (15828, 15829) performed for a cosmetic reason (V50.1) will be denied as non covered.
9. The following CPT codes/procedures are generally considered cosmetic and may be medically reviewed or denied as non-covered:
11950-11954 Injection of filling material (collagen)
15780, 15782, 15783 Dermabrasion (eg. acne scarring, fine wrinkling…)
15832-15839 Excision, excessive skin and subcutaneous tissue, including lipectomy
15876-15879 Suction -assisted lipectomy
17340 Cryotherapy for acne
17360 Chemical exfoliation
10.Billing for dermal injections for the treatment of Facial Lipodystrophy Syndrome (LDS) that meet the criteria in the NCD:
G0429 Dermal Filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g.,as a result of highly active antiretroviral therapy)
Q2026 Radiesse injection Injection, Radiesse, 0.1ml
Q2027 Sculptra injection Injection, Sculptra, 0.1ml
C9800 Dermal injection procedure(s) for facial lipodystrophy syndrome (LDS) and provision of Radiesse or Sculptra dermal filler, including all items and supplies.
1. Claims do not have to be submitted for cosmetic procedures. However, if a denial of Medicare coverage is necessary, a GY modifier (items or services statutorily excluded or does not meet the definition of any Medicare benefit) can be used on a cosmetic procedure to receive a non-covered denial.
2. All submitted non-covered or no payment claims using condition code 21 will be processed to completion, and all services on those claims, since they are submitted as non-covered, will be denied. The default liability for payment of these claims is assigned to the beneficiary, who may then submit the denial from Medicare, as the primary payer, to subsequent payer(s) for consideration. Since a denial is a Medicare determination of payment, all services submitted on no payment claims may be appealed later if unusual circumstances so warrant. That is, all payment determinations are subject to appeal, even denials of services submitted as non-covered.