Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A58774 (Billing and Coding: Cosmetic and Reconstructive Surgery) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A58774: Billing and Coding: Cosmetic and Reconstructive Surgery (Billing and Coding, effective 2026-06-25)
- Covered ICD-10-CM codes
- 222
- 10 groups
- Non-covered ICD-10-CM codes
- 1
- Procedure codes listed
- 72
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| B20 | Human immunodeficiency virus [HIV] disease |
| C30.0 | — |
| C41.0 | — |
| C43.31 | — |
| C43.39 | — |
| C44.300 | — |
| C44.301 | — |
| C44.309 | — |
| C44.310 | — |
| C44.311 | — |
| C44.319 | — |
| C44.320 | — |
| C44.321 | — |
| C44.329 | — |
| C44.390 | — |
| C44.391 | — |
| C44.399 | — |
| C44.501 | — |
| C44.511 | — |
| C44.521 | — |
| C44.591 | — |
| C50.011 | — |
| C50.012 | — |
| C50.021 | — |
Procedure codes: 11920, 11921, 11922, 11950, 11951, 11952, 11954, 15775, 15776, 15780, 15781, 15782, 15783, 15788, 15789, 15792, 15793, 15824, 15825, 15826, 15828, 15829, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879, 17340, 17360, 17380, 19300 and 32 more in the article.
Coverage indications, limitations and medical necessity
• According to the American Society of Plastic and Reconstructive Surgeons, the specialty of plastic surgery includes reconstructive and cosmetic procedures:
Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease. It is generally performed to improve function, may also be done to approximate a normal appearance, and may be covered as surgery is considered reconstructive in nature.
Cosmetic surgery is performed to reshape normal structures of the body to improve the patient's appearance and self-esteem. Please refer to CMS IOM Publication 100-02, Medicare Benefit Policy Manual , Chapter 16: Section 120 for detailed information.
• Corrective facial surgery will be considered cosmetic rather than reconstructive when there is no functional impairment present. However, some congenital, acquired, traumatic or developmental anomalies may not result in functional impairment, but are so severely disfiguring (e.g. but not limited to severe burns or repair of the face following a serious automobile accident) as to merit consideration for corrective surgery.
• Treatment of complications arising from cosmetic surgery will be considered reasonable and necessary if infection, hemorrhage or other serious documented medical complication occurs, and the beneficiary has been officially discharged from the facility.
Per the Medicare Benefit Policy Manual cosmetic surgery or expenses incurred in connection with such surgery, for the sole purpose of improving one’s appearance, is not covered.
Indications for specific surgical procedure
• Breast reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is covered.
• Removal or revision of a breast implant whether placed for reconstructive or cosmetic reasons, is considered medically necessary when it is removed for 1 of the following reasons: 26
• Mechanical complication of breast prosthesis; including rupture or failed implant, and/or implant extrusion.
• Infection or inflammatory reaction due to a breast prosthesis; including infected breast implant, or rejection of breast implants.
• Other complications of internal breast implant; including siliconoma, granuloma, interference with diagnosis of breast cancer, and/or painful capsular contracture with disfigurement.
• Breast Reduction is the surgical reshaping of the breasts to reduce, or lift enlarged or sagging breasts. Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit.
Macromastia (breast hypertrophy) is an increase in the volume and weight of breast tissue relative to the general body habitus. Breast hypertrophy may adversely affect other body systems: musculoskeletal, respiratory, and integumentary. Unilateral hypertrophy may result in symptoms following contralateral mastectomy.
Medical necessity for breast reduction is limited to circumstances in which:
• There are signs and/or symptoms resulting from the enlarged breasts (macromastia) that have not responded adequately to non-surgical interventions,
• To improve or correct asymmetry following cancer surgery on 1 breast.
Note: either the involved breast or contralateral breast may be treated to achieve symmetry.
Note: For coverage indications for contralateral reconstruction of an unaffected breast following a medically necessary mastectomy, refer to the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §140.2.
Non-surgical interventions preceding breast reduction should include as appropriate, but are not limited to, the following:
• Determining macromastia is not due to an active endocrine or metabolic process.
• Determining the symptoms are refractory to properly fitted supportive garments, or following unilateral mastectomy, persistent with an appropriately fitted prosthesis or reconstruction therapy at the site of the absent breast.
• Determining that dermatologic signs and/or symptoms are refractory to, or recurrent following, a completed course of medical management.
A medically reasonable and necessary breast reduction could be indicated in the presence of significantly enlarged breasts and the presence of at least 1 of the following signs and/or symptoms:
• Back, neck or shoulder pain from macromastia and unrelieved by 6 months of:
- Conservative analgesia,
- Supportive measures (garment, etc.),
- Physical Therapy, or
• Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity, or
• Intertriginous maceration or infection of the inframammary skin refractory related to dermatologic measures.
• Permanent shoulder grooving with skin irritation by supporting garment (bra strap).
The amount of breast tissue to be removed must be proportional to the body surface area (BSA) per the Schnur18 scale below. If the individual’s body surface area and weight of breast tissue removed fall above the 22 nd percentile, then the surgery is considered medically reasonable and necessary with the appropriate criteria. If only 1 breast meets the Schnur scale criteria; breast tissue may be removed from the other breast to achieve symmetry.
Schnur Scale:
Body Surface
Area (m2)
Average grams of tissue per breast to
be removed
1.40-1.50
218-260
1.51–1.60
261-310
1.61-1.70
311-370
1.71-1.80
371-441
1.81-1.90
442-527
1.91-2.00
528-628
2.01-2.10
629-750
2.11-2.20
751-895
2.21-2.30
896-1068
2.31-2.40
1069-1275
2.41-2.50
1276-1522
2.51-2.60
1523-1806
2.61-2.70
1807-2154
2.71-2.80
2155-2568
2.81-2.90
2569-3061
2.91-3.00
3062-3650
Mastectomy for gynecomastia
Gynecomastia is the excessive growth of the male mammary glands. These conditions can cause significant clinical manifestations when excessive breast weight adversely affects the supporting structures of the shoulders, neck, and trunk. 32
Mastectomy with nipple preservation or reduction mammoplasty is considered reconstructive and a covered service for males with gynecomastia Grade III and IV or abnormal breast development with redundancy.
• Persists more than 3 to 4 months after the pathological causes are ruled out (e.g. not limited to testosterone deficiency, testicular tumor, liver disease, or drug induced). 32
• Persists after 3 to 4 months of unsuccessful medical treatment for pathological gynecomastia. 16
• Pain or tenderness directly related to the breast tissue which has a clinically significant impact upon activities of daily living.
• Clinical symptoms refractory to a trial of analgesics or anti-inflammatory agents.
• For significant clinical manifestations, when the excessive breast weight adversely affects the supporting structures of the shoulders, neck and trunk.
American Society of Plastic Surgeons’ gynecomastia scale: 16
• Grade I: Small breast enlargement with localized button of tissue that is concentrated around the areola.
• Grade II: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest.
• Grade III: Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present.
• Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast.
Gigantomastia of Pregnancy
Medicare considers subtotal mastectomy or reduction mammoplasty for the unusual condition of Gigantomastia of Pregnancy accompanied by any of the following complications (and delivery is not imminent) medically reasonable and necessary when signs or symptoms are refractory to medical treatment or physical interventions have not adequately alleviated symptoms such as:
• Massive infection 29
• Significant hemorrhage 29
• Tissue necrosis with slough
• Ulceration of breast tissue 29
• Intertriginous maceration or infection of the inframammary skin refractory to dermatologic measures. 29
Tattooing
The policy text continues in the CMS record.
Summary of evidence (opening)
The American Society of Plastic Surgeons explains Plastic Surgery can include both reconstructive and cosmetic procedures. 1 Typically reconstructive surgery is considered medically necessary to restore function and normal appearance, and to correct deformities that are congenital, trauma related or created by medical conditions such as cancer. Cosmetic surgery is not considered medically necessary as it is performed to reshape and adjust normal anatomy to enhance appearance. Certain conditions can be considered either reconstructive or cosmetic depending on the patient’s specific situation. An example of this is rhinoplasty which may be performed to enhance the person’s appearance which is cosmetic but also may be necessary to restore normal breathing and appearance after a trauma such as a fracture which is reconstructive. Often rhinoplasty is performed with other procedures which involve the nasal septum, nasal valve, nasal turbinates, or the paranasal sinuses. When adjunctive procedures are performed that do not change the nasal shape or appearance, they do not meet the definition of rhinoplasty. Rhinoplasty performed to address functional abnormalities may inadvertently change the shape or appearance of the nose.
Rhinoplasty/Septoplasty
Ishii et al 13 created clinical guidelines to provide evidence-based recommendations for the treatment of patients who are candidates for rhinoplasty. Rhinoplasty ranks among the most commonly performed cosmetic surgery in the United States. Rhinoplasty should be considered more than just for cosmetic reasons as it is often medically necessary to improve nasal respiration and relieve any congenital or acquired airway obstructions. While Rhinoplasty may be performed to address a functional abnormality, it may also change or enhance the appearance of the nose. Rhinoplasty is often performed with adjunctive procedures that involve the nasal septum, nasal valve, nasal turbinates, or the paranasal sinuses. When these accompanying procedures are performed without an impact on the nasal shape or appearance, they do not meet the definition of Rhinoplasty.
These guidelines were created by a Guideline Development Group that consisted of 16 members representing experts in plastic surgery, facial plastic and reconstructive surgery, otolaryngology, otology, rhinology, sleep medicine, psychiatric, advanced practice nursing, and consumer advocacy. Three literature searches were performed from May 2015 through December 2015 to identify clinical practice guidelines, systematic reviews, and randomized controlled trials. After all exclusion methods the literature resulted in 1 guideline, 22 systematic reviews, and 19 randomized controlled trials. This information was used to gather evidence, relevant treatments, and outcomes.
The contractor cites 32 sources in the bibliography; the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2021-11-14
- Current revision effective
- 2026-08-27
- Last reviewed by the contractor
- 2026-07-22
- MCD version
- 12
The contractor lists 4 National Coverage Determinations as related: NCD 140.2 Breast Reconstruction Following Mastectomy, NCD 140.4 Plastic Surgery to Correct "Moon Face", NCD 250.4 Treatment of Actinic Keratosis, NCD 250.5 Dermal Injections for the Treatment of Facial Lipodystrophy Syndrome (LDS). Where an NCD speaks, it controls; the LCD can only address what the NCD leaves open.
Other related documents: A59903 (Response to Comments).
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Wisconsin Physicians Service Insurance Corporation hub lists every other active policy from the same contractor.
The same policy title at other contractors
Contractors often adopt each other's policies and then revise them separately, so the criteria and the diagnosis lists drift apart. The topic comparison lines up every version.
Frequently asked questions
What does LCD L39051 cover?
• According to the American Society of Plastic and Reconstructive Surgeons, the specialty of plastic surgery includes reconstructive and cosmetic procedures: The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L39051 apply to?
Wisconsin Physicians Service Insurance Corporation applies it to Medicare claims in AK, AL, AR, AZ, CA, CO, CT, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L39051?
The companion billing and coding article A58774 lists 222 ICD-10-CM codes in 10 groups that support medical necessity and 1 that do not; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L39051?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.