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Cosmetic and Reconstructive Surgery - Medicare Advantage (Revised)
Act
by Sep 30, 2026
Effective date
Oct 1, 2026
Identified
Sep 29, 2026
Summary
This is a comprehensive Medicare Advantage policy revision for cosmetic and reconstructive surgery procedures, effective October 1, 2026. The policy defines coverage criteria for reconstructive procedures (requiring functional impairment documentation), establishes jurisdiction-specific LCD requirements, and specifies medical necessity standards for procedures including benign skin lesion removal, hair removal, keloid removal, panniculectomy, and rhinoplasty/septoplasty. Billing teams must ensure claims align with applicable MAC jurisdictional LCDs and include proper medical necessity documentation.
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What to do
by Sep 30, 2026 · 6 steps
01Billing team must update internal policy references and LCD lookup tables to reflect the revised Humana HUM-1064-006 policy for all Medicare Advantage claims.
02Identify your applicable MAC jurisdiction (J5, J8, J6/JK, J15, JE/JF, JH/JL, JJ/JM, JN) and ensure the corresponding LCD is loaded in your billing system for cosmetic and reconstructive surgery cases.
03For CPT codes 17110, 11400-11404, 11406, 17106-17108, 17380, 11446, 20910, 15830, 30400-30435, 30450, 30460, 30462, 30468: update claim edit rules to require medical necessity documentation demonstrating functional impairment or reconstructive (non-cosmetic) indication.
04Providers and clinical staff must document in medical records whether procedures are reconstructive (with functional impairment) or cosmetic per policy definitions.
05Billing team must verify each claim against the specific MAC's LCD criteria before submission; claims lacking proper documentation will be denied.
06Update encounter forms and prior authorization request templates to capture whether procedures meet reconstructive criteria (congenital defects, trauma, tumor, disease, infection, or developmental abnormality with functional impairment).
Codes mentioned
1711011400114011140211403114041140617106171081710717380114462091015830304003041030420304303043530450304603046230468
Original notice
Cosmetic and Reconstructive Surgery - Medicare Advantage (Revised)
mcp.humana.com · Always check the source before changing claims.
Related changes
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Related policy hubs
Humana policiesPlastic SurgeryDermatologyGeneral SurgeryOral & Maxillofacial SurgeryENT (Ear, Nose & Throat)Code 17110Code 11400Code 11401Code 11402Code 11403Code 11404Code 11406Code 17106Code 17108Code 17107Code 17380Code 11446Code 20910Code 15830Code 30400Code 30410Code 30420Code 30430Code 30435Code 30450Code 30460Code 30462Code 30468