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.
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.
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.
Cosmetic Services Denials
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.
The following CPT codes will be denied for cosmetic reasons.
Reduction Mammoplasty. This procedure will be denied when performed for a cosmetic reason (V50.1).
Mastectomy for gynecomastia. If the tissue removed is primarily fatty tissue, the surgery is classified as cosmetic (V50.1) and will be denied as non-covered.
CPT 15775 – CPT 15776
Punch graft hair transplant. To indicate this procedure is performed for cosmetic reasons, use (V50.0) hair transplant to receive a non-covered denial.
CPT 30400 – CPT 30450
Rhinoplasty. 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.
Excision, excessive skin and subcutaneous tissue (including lipectomy); abdomen (abdominoplasty) is not covered when performed to improve the patient’s appearance (V50.1).
CPT 15788 – CPT 15793
Chemical Peel. For cosmetic reasons (V50.1) will be denied as not covered.
Dermabrasion, segmental, face. Performed for a cosmetic reason (V50.1) will be denied as non-covered.
CPT 15828 & CPT 15829
Rhytidectomy. Performed for a cosmetic reason (V50.1) will be denied as non covered.
Other CPT Codes
The following CPT codes/procedures are generally considered cosmetic and may be medically reviewed or denied as non-covered:
- CPT 11950 – CPT 11954: Injection of filling material (collagen)
- CPT 15780, CPT 15782, CPT 15783: Dermabrasion (eg. acne scarring, fine wrinkling…)
- CPT 15819: Cervicoplasty
- CPT 15824 – CPT 15826: Rhytidectomy
- CPT 15832 – CPT 15839: Excision, excessive skin and subcutaneous tissue, including lipectomy
- CPT 15876 – CPT 15879: Suction -assisted lipectomy
- CPT 17340: Cryotherapy for acne
- CPT 17360: Chemical exfoliation
- CPT 17380: Electrolysis
- CPT 69300: Otoplasty
Codes That Will Be Reimbursed
Billing for dermal injections for the treatment of Facial Lipodystrophy Syndrome (LDS) that meet the criteria in the NCD:
Dermal Filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g.,as a result of highly active antiretroviral therapy).
Radiesse injection Injection, Radiesse, 0.1ml
Sculptra injection Injection, Sculptra, 0.1ml
Dermal injection procedure(s) for facial lipodystrophy syndrome (LDS) and provision of Radiesse or Sculptra dermal filler, including all items and supplies.