N.J. Admin. Code § 10:54-5.3

Current through Register Vol. 56, No. 23, December 2, 2024

Section 10:54-5.3 - Cosmetic surgery

(a) Cosmetic surgery means that surgery, which is performed solely for the purpose of beautifying an individual and which has no significant redeeming medical necessity. For purposes of the New Jersey Medicaid/NJ FamilyCare program, cosmetic surgery is not a covered or reimbursable service, except as specified in (b) below.

(b) If significant redeeming medical necessity can be demonstrated, the medical consultant in the Medical Assistance Customer Center (MACC) will consider a request from a physician for prior authorization to perform such surgery. Such requests shall be submitted in writing and shall include photographs, when indicated, to support the request. The physician shall obtain prior authorization from the Medical Assistance Customer Center before this service is rendered. (See directory of Medical Assistance Customer Centers at N.J.A.C. 10:49, Appendix.)

(c) Repair or reconstruction of changes due to trauma, infection or surgery whose need for correction demonstrates a significant medical necessity is not considered cosmetic surgery within the intent of the New Jersey Medicaid/NJ FamilyCare program and therefore would not require prior authorization.

N.J. Admin. Code § 10:54-5.3

Amended by R.2001 d.51, effective 2/5/2001.
See: 32 N.J.R. 3929(a), 33 N.J.R. 555(a).
In (b), substituted references to the Medical Assistance Customer Center for references to the Medicaid District Office throughout.
Amended by R.2012 d.124, effective 7/2/2012.
See: 43 N.J.R. 1477(a), 44 N.J.R. 1884(a).
In (a), inserted a comma following the second occurrence of "surgery"; and in (a) and (c), inserted "/NJ FamilyCare".