Applies to:

Commercial group HMO, EPO, POS and PPO plans

Commercial individual MyPriority® plans

Priority Health Choice plans (Medicaid and Healthy Michigan Plan)

Priority Health Medicare plans

Definition

Therapeutic reconstructive surgeries include repair of congenital anomalies, treatment for accidental injuries, facial scar revisions, port wine stains and vascular malformations. 

Cosmetic surgery is performed on normal structures of the body primarily to improve appearance and/or self-esteem rather than to restore the anatomy and/or functions of the body that are lost or impaired due to an illness or injury. Cosmetic surgery is not considered a medical necessity.

Medical policy

• Cosmetic and Reconstructive Surgery Procedures - 91535

Cosmetic and reconstructive surgery coverage

For commercial group and individual plans, and usually for employer group Medicare plans, therapeutic reconstructive surgeries are covered only when necessary due to improve function. Therapies and procedures intended to change or restore appearance for cosmetic purposes are not a covered benefit. See the criteria in the medical policy, above.

When these surgeries meet coverage criteria, they're covered at non-standard cost-sharing levels.

Non-standard cost-sharing

If/when commercial employer group and MyPriority^® individual plans cover certain surgeries, these surgeries may be covered at a different cost-sharing level than our standard benefit coverage levels.

To verify member cost sharing and coverage, use the Member Inquiry tool and look in the Additional benefits drop-down menu for Certain surgeries benefit information.

Cosmetic and reconstructive surgery authorizations

Prior authorization is required for select procedures. See criteria in the medical policy.