Cosmetic and Reconstructive Surgery

Medically necessary reconstructive procedures are covered when performed to correct abnormal structures from congenital, traumatic, infectious, neoplastic, or disease-related causes or to restore function; many cosmetic procedures are explicitly non-covered. Specific covered services include post-mastectomy breast reconstruction (including contralateral reconstruction), implant removal for implant-related complications, breast reduction meeting clinical and Schnur scale criteria, gynecomastia surgery meeting grade/duration/treatment-failure criteria, select nasal procedures with documented failed conservative therapy, dermabrasion/chemical peel for defined disease states, dermal injections for HIV-related facial lipodystrophy with associated depression, and panniculectomy for documented chronic intertrigo or functional impairment with weight-stability requirements. Documentation of prior conservative therapy, objective measures (e.g., Schnur scale, episode counts), duration thresholds (e.g., 6 weeks, 3 months, 6 months, 18 months), and relevant diagnostic/exclusion workups is required; cosmetic-only indications and several specified procedures (e.g., liposuction for contouring, elective rhinoplasty without functional abnormality) are not covered.