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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 9, 2026
Days to comply

Summary

This is a revised Medicare Advantage policy on cosmetic and reconstructive surgery effective March 2, 2026. The policy clarifies coverage criteria for multiple procedures including benign skin lesion removal, hair removal, keloid removal, panniculectomy, rhinoplasty/septoplasty, and scar revision. It establishes that reconstructive surgery requires documented functional impairment, and references jurisdiction-specific Local Coverage Determinations (LCDs) by Medicare Administrative Contractor (MAC) regions.

Action Required

Action needed
By March 2, 2026: Billing team must update systems to align with this revised Medicare Advantage policy. (1) Verify your practice's MAC jurisdiction using the provided table (J5, J6, J8, J15, JE, JF, JH, JL, JJ, JM, or JN) to identify applicable LCDs. (2) Update prior authorization requirements for skin lesion removal (CPT 17110, 11400-11406), hair removal (CPT 17380), keloid removal (CPT 11400-11446), panniculectomy (CPT 15830), and rhinoplasty/septoplasty (CPT 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30468) based on jurisdiction-specific LCDs. (3) Ensure all reconstructive surgery claims include documentation of functional impairment (defined as direct, measurable reduction in physical performance). (4) For hair removal, limit coverage to recurrent pilonidal cyst cases post-surgery; for keloid removal, require functional impairment documentation; for panniculectomy, apply LCD criteria from your jurisdiction. (5) Update billing software and encounter forms to reflect these requirements. Providers must document medical necessity per jurisdiction guidance. Claims lacking required documentation or prior authorization will be denied.

Affected Billing Codes

17110
11400
11401
11402
11403
11404
11405
11406
17106
17108
17107
17380
11446
20910
15830
30400
30410
30420
30430
30435
30450
30460
30462
30468