Plastic and Reconstructive Surgery Prior Authorization and Denial Guide
Breast reconstruction Women's Health and Cancer Rights Act mandate, functional blepharoplasty visual field documentation requirements, reduction mammaplasty specimen weight thresholds, and panniculectomy medical necessity documentation for plastic surgery billing. Grounded in the Women's Health and Cancer Rights Act (WHCRA) of 1998, Aetna Medical Policy for breast reconstruction, UHC CDG Plastic and Reconstructive Surgery, and operative payer coverage criteria.
Breast reconstruction: the WHCRA (29 U.S.C. §1185b) requires group health plans that cover mastectomy to also cover breast reconstruction, including all stages of reconstruction, surgery on the contralateral breast to produce a symmetrical appearance, prostheses, and treatment of complications. Prior authorization is required from most commercial payers for breast reconstruction. Documentation requirements for immediate reconstruction (at time of mastectomy) and delayed reconstruction differ — delayed reconstruction typically requires documentation of oncologic treatment completion and clearance. Both implant-based and autologous reconstruction are covered under the WHCRA mandate.
Functional blepharoplasty (CPT 15822, 15823): prior authorization requires documentation of visual field restriction — most payers require Humphrey visual field testing with lid in natural position showing restriction of ≥30° in the superior visual field, and improvement to normal limits when the lid is manually elevated. Clinical photographs demonstrating the mechanical ptosis are required. Panniculectomy (CPT 15830) requires documentation of intertrigo or rash under the pannus that has been refractory to conservative treatment for at least 3–6 months, with photographs and dermatology or wound care documentation. Weight loss surgery history strengthens the pannus redundancy justification for most payers.