Cosmetic and Reconstructive Procedures

This policy covers medically necessary reconstructive surgical and nonsurgical services — including craniofacial reconstruction (any age), TMJ/craniomandibular treatment, post‑mastectomy breast reconstruction and prostheses, scleral contact lenses, and hearing aids — when intended to restore appearance or correct a functional impairment from trauma, congenital/developmental defects, pathology, or mastectomy. Coverage is limited to specified fully insured products and state mandates (e.g., Illinois Medicaid; HCSC members in Arkansas and Mississippi), requires documented functional impairment and adherence to member contract benefits (ASO groups may be excluded unless elected), and includes specific limits such as one set of scleral lenses per year and two hearing aids/molds per ear every two years.

"Medically necessary reconstructive services intended to restore physical appearance of body structures damaged by trauma."