Cosmetic and Reconstructive Procedures (BSC7.08)

By August 15, 2026: Billing team must update claims processing system and prior authorization workflows to enforce the following: (1) For reconstructive procedures (CPT 21740-21743 for chest wall deformities, 11200-11201 for benign lesions, 17106-17108 for hemangiomas, 11400-11446 for hypertrophic scars), require documentation of functional impairment or need to normalize appearance before authorizing claims. (2) For pectus excavatum cases, verify Haller index ≥3.25 and evidence of cardiac/pulmonary impairment or exercise intolerance via CPET before approval. (3) Flag all claims for cosmetic procedures (CPT 19325 breast augmentation, 19316 breast lift, 15775-15776 hair transplant, 11920-11922 tattoo removal, 17380 hair removal) as non-covered unless submitted with medical exception documentation showing significant functional deficit unresponsive to conservative treatment. (4) Update encounter forms and provider education materials to distinguish reconstructive (covered) from cosmetic (non-covered) indications. (5) Providers must submit objective documentation including measurements, test results, photographs, and conservative treatment history for medical review requests. Failure to apply these criteria will result in claim denials and potential overpayment recovery.