Costs Connected with Cosmetic Surgery Are Not Covered

Date Issued: 3/27/2015

The Centers for Medicare and Medicaid Services (CMS) recently changed their guidelines for cosmetic procedures to include any services related to a noncovered cosmetic procedure. EmblemHealth is complying with the CMS guidelines and instituting them across all of our networks and plans. Our policy on cosmetic surgery is that EmblemHealth does not cover cosmetic procedures under the following circumstances:

  1. When the procedure is performed solely for psychological reasons.
  2. In the absence of documentation that substantiates the procedure is being performed to restore or improve bodily function or is medically necessary.

Ancillary services related to cosmetic procedures are not considered medically necessary and are also not covered.

All cosmetic surgery requires prior approval. You may view EmblemHealth’s medical policy on cosmetic surgery in the Medical Policies section of our website. For additional information you may review the CMS guidelines on cosmetic surgery at the CMS website.