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The following procedures are nearly always cosmetic in nature. They are only covered when case review justifies a medical exception. |
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Procedure |
CPT Code(s) |
ICD-9 |
|
Excision, excessive skin, thigh, leg, hip, buttock arm, forearm or hand, submental fat pad; other areas |
15831 15832-39 |
86.83 86.3 |
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Chemical Peel |
15788-15793 |
86.3 |
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Salabrasion |
15810, 15811 |
86.3 |
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Dermabrasion for removal of acne scars |
15780-15787 |
86.25 |
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Chemical Exfoliation for acne |
17360 |
86.24 |
|
Grafts, fat |
15770, 20926 |
86.89 |
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Electrolysis for hirsutism |
17380 |
86.92 |
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Suction assisted lipectomy |
15876-15879 |
86.83 |
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Correction diastasis recti abdominis |
|
83.65 |
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Removal of spider angiomata |
36468, 36469 |
39.92 |
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Reduction of labia minora |
56620 |
71.3 |
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Zyderm collagen implant |
11950-11954 |
86.02 |
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The following procedures will be covered if deemed to be medically necessary. (Photographs, medical records and letter documenting medical necessity may be required) |
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Procedure |
CPT code(s) |
ICD-9 |
|
Abdominal lipectomy |
15877 |
86.83 |
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Blepharoplasty |
15820-15823 |
08.31-08.89 |
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Breast reconstruction |
19318, 19340, 19396 |
85.7 |
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Dermabrasion |
15780-15787 |
86.25 |
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Gynecomastia |
19318 |
85.20 |
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Hair transplant |
15775, 15776 |
86.64 |
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Keloids |
11400-11471 |
86.3 |
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Lipomas |
11400-11471 |
86.3 |
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Otoplasty |
69300 |
18.79 |
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Port wine stains and other hemangiomas |
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Rhinoplasty |
30460-30462 |
21.85-21.87 |
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Rhytidectomy (meloplasty, face lift) |
15824-15829 |
86.82 |
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Scar Revision |
11400-11471 with 12001-12021 |
86.84 |
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Septoplasty |
30520 |
21.88 |
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Skin Tag Removal |
11200, 11201 |
86.3 |