Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Most medical plans administered by QualChoice do not cover cosmetic surgery.

2)    Cosmetic and reconstructive surgeries must be submitted to QualChoice for a coverage determination prior to performance of the surgery.

3)     The plan definition of cosmetic surgery will be applied in determining which procedures may be covered. You should check your plan documents to see which (if any) cosmetic procedures may be covered.

4)    Breast Reconstruction: See BI366.

5)    Craniofacial anomaly reconstruction:  See BI498.

1)    Most plans administered by QualChoice do not cover cosmetic surgery. Please check the plan documents for definition of cosmetic surgery and possible coverage exceptions.

2)    Any planned surgery which might be construed as cosmetic should be submitted to QualChoice before the surgery is performed for a determination of whether it would be covered or not.

3)    The standard definitions used by QualChoice for our fully insured lines of business are:

a)    Reconstructive Surgery: Surgery that is necessary to restore part of the body that is injured or deformed by acute trauma, infection or other pathological disease that occurred while the Enrollee is covered under this plan (or under a qualifying plan preceding this plan).  Also, it is surgery necessary to correct congenital malformations or anomalies that result in a severe functional impairment in a child covered under this plan.

b)    Cosmetic Surgery: Surgery that is done primarily to improve appearance or for psychological benefit; when there is ambiguity, any appearance-altering surgery which does not fit the definition of Reconstructive Surgery will be considered Cosmetic.

4)    Breast Reconstruction: See BI366.

5)    Craniofacial anomaly reconstruction:  See BI498.

1)    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:

a)    Rhinoplasty

b)    Rhytidectomy or Rhytidoplasty

c)    Blepharoplasty without visual impairment

d)    Otoplasty

e)    Breast augmentation

f)     Breast reduction (unless listed in the contract booklet) – see BI026 Reduction Mammoplasty.

g)    Removal of skin tags and keloids.

2)    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.

3)    Refer to member contract booklet for any specific exclusions/language.

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD,  EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.