Cosmetic and reconstructive surgeries

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.

Medical policy

Therapeutic reconstructive surgeries 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. 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 are covered at a different cost-sharing level than our standard benefit coverage levels.

To verify member cost sharing, 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 therapeutic reconstructive surgery and for surgery to improve clinical functional impairment. See criteria in the medical policy.