Medicare AdvantageCoverageMedium impact
Cosmetic and Reconstructive Surgery - Medicare Advantage (Revised)
Humana·Plastic Surgery, Dermatology, General Surgery +1 more·Medicare Advantage
Effective date
Mar 2, 2026
We identified it
Sep 5, 2026
Summary
This is a revised Medicare Advantage policy (effective 03/02/2026) on cosmetic and reconstructive surgery coverage that consolidates national coverage rules and references applicable MAC Local Coverage Determinations by geographic jurisdiction. The policy clarifies which procedures are covered (reconstructive only, with specific functional impairment criteria), which require medical necessity documentation, and directs billing teams to apply jurisdiction-specific LCDs for benign skin lesion removal, panniculectomy, rhinoplasty/septoplasty, and other procedures. Key update: Hair removal (CPT 17380) is now restricted to recurrent pilonidal cyst cases only.
Action Required
By March 2, 2026: Billing team must update claim submission logic to apply the correct Medicare Administrative Contractor (MAC) Local Coverage Determination (LCD) based on patient geographic jurisdiction (J5, J8, J6, JK, JE, JF, JH, JL, JJ, JM, JN listed in policy). For benign skin lesion removal (CPT 17110, 11400-11406), panniculectomy (CPT 15830), rhinoplasty/septoplasty (CPT 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30468), and cutaneous vascular lesion removal (CPT 17106, 17108, 17107): implement jurisdiction-specific LCD criteria in billing system. For CPT 17380 (hair removal), flag all requests and require clinical documentation proving recurrent pilonidal cyst history—all other hair removal claims will be denied. For keloid removal (CPT 11400-11446), require documentation of functional impairment. Ensure providers document that reconstructive procedures address functional impairment or medical illness per policy definition. Update prior authorization templates to reference applicable LCD for each MAC jurisdiction. Failure to apply correct LCD criteria will result in claim denials and overpayments.