QualChoice will not pay for any procedures, anesthesia, services, equipment, or
supplies provided in connection with purely elective cosmetic surgery (Diagnosis
code Z41.1 – Encounter for cosmetic surgery). Examples of non-covered procedures
include, but are not limited to the following:
Rhytidectomy or Rhytidoplasty
Blepharoplasty without visual impairment
reduction (unless listed in the contract booklet) – see BI026 Reduction
skin tags and keloids.
Exceptions will be considered when a request for a coverage exception is made
prior to the surgery. For example, a Rhinoplasty to correct a defect caused by
a traumatic injury might be covered as reconstructive surgery (Diagnosis code
Z42.8 – Encounter for other plastic/reconstructive surgery following medical
procedure or healed injury). If there is any concern that a surgery that would
ordinarily be considered to be cosmetic might be covered as reconstructive, an
advance determination should be requested from the Care Management Department,
by submission of a complete explanation, including sufficient medical record to
substantiate the genesis of the defect, the nature of the functional impairment
and the rationale for the specific choice of intervention. When such a
procedure has been pre-authorized, the claim will be paid.
member contract booklet for any specific exclusions/language.