CurrentCareSource GeorgiaPolicy MCD-MM-0732

Breast Reconstruction Surgery

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This policy governs CareSource Georgia Medicaid coverage for breast reconstruction surgery, treatment of physical complications after reconstruction, and related nonsurgical breast prostheses and mastectomy bras. It applies to members seeking reconstruction after mastectomy or breast-conserving surgery and to members with specified congenital, disease-related, traumatic, or postsurgical indications.

Policy Summary

PayerCareSource Georgia

PolicyBreast Reconstruction Surgery

Policy CodePolicy MCD-MM-0732

Change TypeRevised policy

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review DateN/A

Key ActionVerify that the indication meets an applicable coverage criterion and is not excluded as cosmetic or unproven.

SourceLink

POLICY UPDATE CHANGES

The policy was revised to reference MCG criteria S-862 and S-864 for clarity regarding breast reconstruction indications.

The review history states that a breast cancer requirement was removed from some criteria.

The policy review history states that risk-reducing mastectomy coverage and the policy organization were updated.

The policy was reviewed and approved for an effective date of July 1, 2026, with updated references.

6Listed alternative clinical indications

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CurrentCareSource GeorgiaPolicy MCD-MM-0732

Breast Reconstruction Surgery

Customize your policy alerts

Sign up for caresourcegeorgia Policy MCD-MM-0732 alerts

Get alerted when Policy MCD-MM-0732 changes without checking for updates manually.

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Policy Summary

PayerCareSource Georgia

PolicyBreast Reconstruction Surgery

Policy CodePolicy MCD-MM-0732

Change TypeRevised policy

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review DateN/A

Key ActionVerify that the indication meets an applicable coverage criterion and is not excluded as cosmetic or unproven.

SourceLink

POLICY UPDATE CHANGES

The policy was revised to reference MCG criteria S-862 and S-864 for clarity regarding breast reconstruction indications.

The review history states that a breast cancer requirement was removed from some criteria.

The policy review history states that risk-reducing mastectomy coverage and the policy organization were updated.

The policy was reviewed and approved for an effective date of July 1, 2026, with updated references.

6Listed alternative clinical indications

Breast Reconstruction Coverage Criteria

Initial Breast Reconstruction Medical Necessity

Breast reconstruction is medically necessary when ANY of the following clinical indications apply:

Qualifying indications for breast reconstruction

MCG S-862 pathway: The member meets the outlined criteria in MCG S-862, Mastectomy, Complete, with Insertion of Breast Prosthesis or Tissue Expander.
MCG S-864 pathway: The member meets the outlined criteria in MCG S-864, Mastectomy, Complete, with Tissue Flap Reconstruction.
Congenital deformity: A congenital deformity affects the member’s physical and psychological wellbeing.
Severe fibrocystic breast disease limits the member’s function.
Unintentional trauma or injury: The reconstruction is required because of unintentional trauma or injury.
Unintentional postsurgical complication: An unintentional complication occurred after breast surgery for a nonmalignant condition, such as pain, irritation, bleeding, discharge, or a complication causing difficulty with lactation.

Post-Reconstruction Complications

Treatment of physical complications following breast reconstruction is medically necessary.

Physical complications after reconstruction: Treatment of physical complications, including lymphedema, following breast reconstruction is medically necessary.

See the Women’s Health and Cancer Rights Act for additional information.

Nonsurgical Alternatives

Covered nonsurgical alternatives are limited to the following post-surgical circumstance.

External breast prostheses and mastectomy bras are covered following mastectomy or breast-conserving surgery.

All other nonsurgical indications are considered not medically necessary.

Breast reconstruction procedures considered experimental, investigational, or unproven for the specific indication are not covered.

Procedures considered cosmetic in nature are not covered, including procedures intended to address natural changes associated with aging or weight loss or gain.

Lipectomy for donor-site symmetry is not covered.

Suction lipectomy or ultrasonically assisted suction lipectomy (liposuction) is not covered when performed to correct surgically induced donor-site asymmetry, such as trunk or extremity asymmetry resulting from one or more flap breast reconstruction procedures.

Coverage of nonsurgical alternatives is limited to external breast prostheses and mastectomy bras following mastectomy or breast-conserving surgery. All other indications are considered not medically necessary.

Coding References

Free-Flap Breast ReconstructionCPTCovered

19364

Breast reconstruction with free flap, regardless of technique

MCG Criteria Referencesmixed

S-862	Mastectomy, Complete, with Insertion of Breast Prosthesis or Tissue Expander
S-864	Mastectomy, Complete, with Tissue Flap Reconstruction

Provider Denial Risks

Denial Risk

Excluded or Unproven Procedures

Do not request coverage for breast reconstruction procedures that are experimental, investigational, or unproven for the indication. Coverage is also excluded for cosmetic procedures and specified procedures addressing donor-site symmetry or surgically induced donor-site asymmetry.

Cosmetic procedures, including correction of natural changes due to aging or weight loss/gain, are not covered.
Lipectomy performed for donor-site symmetry is not covered.
Suction lipectomy or ultrasonically assisted suction lipectomy (liposuction) to correct surgically induced donor-site asymmetry of the trunk or extremity resulting from one or more flap breast reconstruction procedures is not covered.

Denial Risk

Unlisted Nonsurgical Indications

For nonsurgical alternatives, coverage is limited to external breast prostheses and mastectomy bras following mastectomy or breast-conserving surgery. All other nonsurgical indications are considered not medically necessary.

External breast prostheses are covered following mastectomy or breast-conserving surgery.

Policy Background

Breast reconstruction is intended to reduce complications after breast surgery, restore breast symmetry, and improve quality of life. Reconstruction may be performed immediately or on a delayed basis and may involve implants, tissue expanders, autologous tissue flaps, nipple reconstruction, breast reduction or augmentation, and breast contouring.

Key Definitions

Breast-conserving surgery

ProcedureBreast-conserving surgery (lumpectomy or partial mastectomy)

Primary removalSurgical removal of a tumor.

Additional tissueA small amount of surrounding tissue is also removed.

Contralateral breast

TermContralateral breast

StatusUnaffected breast.

Surgical relationshipThe nonsurgical breast.