QualChoice will not pay for any procedures, services, equipment, or supplies
provided in connection with elective cosmetic surgery. Examples of non-covered
procedures include, but are not limited to the following:
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. 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.