Introduction

Aetna plans exclude coverage of cosmetic surgery that is not medically necessary, but generally provide coverage when the surgery is needed to improve the functioning of a body part or otherwise medically necessary even if the surgery also improves or changes the appearance of a portion of the body. Additionally, many Aetna plans specify that certain procedures are not considered to be cosmetic surgery (e.g., surgery to correct the result of injury, post-mastectomy breast reconstruction, surgery needed to treat certain congenital defects such as cleft lip or cleft palate). Please check benefit plan descriptions for details.

This policy statement supplements plan coverage language by identifying procedures that Aetna considers medically necessary despite cosmetic aspects, and other cosmetic procedures that Aetna considers not medically necessary. Please note that, while this policy statement addresses many common procedures, it does not address all procedures that might be considered to be cosmetic surgery excluded from coverage. Aetna reserves the right to deny coverage for other procedures that are cosmetic and not medically necessary.

Clinical Statements

The following procedures are considered cosmetic in nature:

• Excision, excessive skin, thigh, leg, hip, buttock, arm, forearm or hand, submental fat pad, other areas (see CPB 211 - Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair )
• Salabrasion
• Grafts, fat
• Electrolysis or laser hair removal
• Suction assisted lipectomy
• Correction of diastasis recti abdominis (see CPB 211 - Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair )
• Removal of spider angiomata
• Vaginal rejuvenation procedures (designer vaginoplasty, revirgination, G-spot amplification, reduction of labia minora)
• Gynecomastia surgery (see CPB 017 - Breast Reduction Surgery and Gynecomastia Surgery )
• Breast augmentation (breast implants and pectoral implants) (for medical necessity criteria for breast reconstruction, see CPB 185 - Breast Reconstructive Surgery) (see also CPB 142 - Breast Implant/Removal )
• Poly-L-lactic acid injection (Sculptra) for HIV lipoatrophy
• Chin implant (genioplasty, mentoplasty)
• Cheek implant (malar implants).

The following procedures are considered medically necessary when criteria are met. The requesting physicians may be required to submit documentation, including photographs, letters documenting medical necessity, chart records, etc.

• Blepharoplasty: Considered medically necessary when criteria in CPB 084 - Ptosis Surgery, are met. Breast reduction: Considered medically necessary when criteria in CPB 017 - Breast Reduction Surgery and Gynecomastia Surgery, are met.
• Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 251 - Dermabrasion, Chemical Peels, and Acne Surgery are met.
• Collagen implant (e.g., Zyderm): Considered cosmetic except as a treatment for urinary incontinence when medical necessity criteria in CPB 223 - Urinary Incontinence Treatments are met.
• Dermabrasion: Considered medically necessary when criteria in CPB 251 - Dermabrasion, Chemical Peel, and Acne Surgery are met.
• Earlobe repair: Repair (e.g., tear) of a traumatic injury is considered medically necessary. Earlobe repair to close a stretched pierce hole, in the absence of a traumatic injury, is considered cosmetic.
• Keloids: Repair of keloids is considered medically necessary if they cause pain or a functional limitation. Note: For repair of keloids that do not cause pain or functional impairment, exceptions to cosmetic surgery exclusion may apply. Please check benefit plan descriptions. See also CPB 551 - Radiation Treatment of Keloids.
• Lipomas: Aetna considers medically necessary excision of lipomas that are tender and inhibit the member's ability to perform daily activities due to the lipomas' location on body parts that are subject to regular touch or pressure.
• Otoplasty: Considered medically necessary when performed to improve hearing by directing sound in the ear canal, whether the ears are absent or deformed from trauma, surgery, disease, or congenital defect. Otoplasty to correct large or protruding ears is considered cosmetic when the surgery will not improve hearing.
• Panniculectomy: Considered medically necessary when criteria are met, as set forth in CPB 211 - Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair.
• Port wine stains and other hemangiomas: Considered medically necessary when lesions are located on the face and neck. See also CPB 559 - Pulsed Dye Laser Treatment.
• Rhinoplasty: Considered medically necessary for indications set forth in CPB 005 - Septoplasty and Rhinoplasty.
• Rhytidectomy (including meloplasty, face lift): Considered medically necessary when there is functional impairment that cannot be corrected without surgery.
• Scar revision: Repair of scars that result from surgery is considered medically necessary if they cause symptoms or functional impairment. Note: Exceptions to cosmetic surgery exclusion may apply to repair of scars that do not cause pain or functional impairment. Please check benefit plan descriptions.
• Septoplasty: Considered medically necessary when criteria are met, as set forth in CPB 005 - Septoplasty and Rhinoplasty.
• Skin tag removal: Considered medically necessary when located in an area of friction with documentation of repeated irritation and bleeding.
• Tattoo: Considered medically necessary in conjunction with reconstructive breast surgery post-mastectomy. See CPB 185 - Breast Reconstructive Surgery.
• Ventral hernia: Considered medically necessary when criteria are met, as set forth in CPB 211 - Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair.

Implantation and attachment of prostheses

Note: Most Aetna plans cover prosthetic devices that temporarily or permanently replace all or part of an external body part that is lost or impaired as a result of disease, injury or congenital defect. The surgical implantation or attachment of covered prosthetics is covered, regardless of whether the covered prosthetic is functional (i.e., regardless of whether the prosthetic improves or restores a bodily function). The following surgical implantations are covered when medical necessity criteria for the prosthetic device are met, even though the prosthetic device does not correct a functional deficit.

The following prostheses are considered medically necessary when criteria are met:

• Testicular prostheses: Considered medically necessary for replacement of congenitally absent testes, or testes lost due to disease, injury, or surgery.
• Breast reconstruction: See CPB 185 - Breast Reconstructive Surgery.
• Eye (ocular) prostheses: See CPB 619 - Eye Prosthesis.
• Ear (auricular) prostheses: See CPB 620 - Facial Prostheses, External.
• Facial prosthesis. See CPB 620 - Facial Prostheses, External.
• Hair transplant: Considered medically necessary when performed to correct permanent hair loss that is clearly caused by disease or injury. Hair transplants performed to correct male pattern baldness or age-related hair thinning in women are considered cosmetic.

See also the following CPBs that address other procedures that may be considered cosmetic:

• CPB 50 - Varicose Veins 
• CPB 95 - Orthognathic Surgery 
• CPB 113 - Botulinum Toxin 
• CPB 251 - Dermabrasion, Chemical Peels, and Acne Surgery 
• CPB 272 - Pectus Excavatum and Poland's Syndrome: Surgical Correction 
• CPB 310 - Thoracoscopic Sympathectomy 
• CPB 419 - Graves' Ophthalmopathy: Surgical Procedures 
• CPB 422 - Vitiligo 
• CPB 427 - Carbon Dioxide Laser for Actinic Lesions of the Skin 
• CPB 547 - Rosacea 
• CPB 566 - Strabismus Repair in Adults 
• CPB 633 - Benign Skin Lesion Removal.