Colorado Rocky Mountain Health Plans Breast Reconstruction Coverage

Coverage Criteria — When Reconstruction Is Medically Necessary

Medically necessary indications

Covered when conditions described below are met

Primary indications: Breast reconstruction during or after mastectomy and for treatment of congenital disorders (e.g., Poland syndrome, Turner syndrome) or severe breast disfigurement (e.g., amastia, radiation-related deformity) are considered reconstructive and medically necessary in certain circumstances; refer to InterQual CP: Procedures, Breast Reconstruction for detailed clinical criteria.

See InterQual for detailed clinical criteria

Procedures considered reconstructive when performed with reconstruction: Creation of a nipple (by various techniques) and areola (including tattooing), mastopexy or breast reduction when required prior to mastectomy to preserve nipple viability, and reconstruction with a breast implant (including tissue expander placement and use of acellular dermal matrix such as AlloDerm, Cortiva, AlloMax, DermACELL, FlexHD) are considered reconstructive when performed as part of breast reconstruction.

ADM examples: AlloDerm, Cortiva, AlloMax, DermACELL, FlexHD

Complication treatments covered: Treatment of post-mastectomy complications is covered, including management of lymphedema (eg, complex decongestive therapy, lymphedema pumps, compression garments/bandages) and treatment of postoperative infections or complications related to reconstruction.

Lymphedema conservative therapies supported by evidence

Implant removal: Removal of breast implants is considered reconstructive and medically necessary for individuals implanted with Allergan BIOCELL textured breast implants regardless of reason for initial placement; removal may be performed with or without capsulectomy/capsulotomy in certain circumstances (see InterQual CP: Procedures, Breast Implant Removal).

Refer to InterQual CP: Procedures, Breast Implant Removal

Correction of inverted nipple(s): Repair of inverted nipples (not related to mastectomy) is reconstructive and medically necessary when there is documented chronic nipple discharge, bleeding, scabbing, or ductal infection, or when inversion is the result of a congenital anomaly.

Reconstructive indications

Covered when reconstructive intent restores appearance or addresses disfigurement from cancer, congenital anomaly with physiologic impact, trauma, radiation, or implant removal with capsulectomy.

General reconstructive coverage: Reconstruction after lumpectomy or mastectomy for breast cancer, reconstruction for congenital anomalies that restore or preserve physiologic function, correction of breast disfigurement from radiation or trauma, and removal of implants (with or without capsulectomy/capsulotomy) are considered reconstructive and eligible for coverage.

Supported by policy description and InterQual reference

Timing of reconstruction: Reconstruction may be performed immediately at the time of the index surgery or delayed until after completion of adjuvant therapy (radiation and/or chemotherapy) or until the member elects reconstruction.

Supported by chunk 18

Coverage exceptions and limits: Coverage is subject to federal, state, and contractual benefit plan requirements which may supersede this policy; a gap exception may be granted if no in‑network provider is available to perform the requested reconstructive procedure. Procedures that correct an anatomical congenital anomaly without improving or restoring physiologic function are considered cosmetic and excluded from coverage.

Procedures that correct an anatomical congenital anomaly but do not improve or restore physiologic function are considered cosmetic and are excluded from coverage. Examples of such excluded procedures include correction of aberrant breast tissue, aspirations, biopsies (open or core), excision of cysts, duct lesion excisions, and excision of fibroadenomas or other benign lesions when done solely for cosmetic reasons.

Procedures that correct anatomical congenital anomalies without restoring physiologic function are considered cosmetic and excluded. Specific examples listed include: aberrant breast tissue, aspirations, open or core biopsies, duct lesion excisions, excision of cysts, excision of fibroadenomas or other benign or malignant tumors, nipple or areolar lesion procedures, treatment of gynecomastia, revision of a prior reconstructed breast for normal aging, and excision of 'dog ear' tissue. These exclusions apply where the intervention does not serve a reconstructive purpose that restores function.

Providers must refer to the applicable federal, state, and contractual benefit plan requirements when determining coverage, because those requirements may differ from the standard benefit plan. In the event of a conflict, the federal, state, or contractual requirements govern. A gap exception may be granted if no in‑network provider is available to provide the requested reconstructive procedure.

Breast reconstruction performed solely to correct asymmetry for indications other than those identified as reconstructive is considered cosmetic and not medically necessary. Requests for reconstruction to address asymmetry must meet reconstructive criteria to be eligible for coverage; otherwise they will be denied as cosmetic.

Breast enhancement procedures and liposuction that are unrelated to mastectomy are considered cosmetic and are excluded from coverage. Examples include breast implants and mastopexy when performed for enhancement rather than reconstruction, and liposuction not performed as part of a covered reconstructive procedure.

Relevant Procedure and Diagnosis Codes

Applicable CPT CodesCPT

11920	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less.
11921	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm.
11922	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure).
11970	Replacement of tissue expander with permanent implant.
11971	Removal of tissue expander without insertion of implant.
15271	Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area.
15272	Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure).
15771	Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate.
15772	Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure).
15777	Implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement (i.e., breast, trunk) (List separately in addition to code for primary procedure).

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Applicable HCPCS/Special CodesHCPCS

L8600	Implantable breast prosthesis, silicone or equal.
S2066	Breast reconstruction with gluteal artery perforator (GAP) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral.
S2067	Breast reconstruction of a single breast with stacked deep inferior epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator (GAP) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateral.
S2068	Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral.
S8950	Complex lymphedema therapy, each 15 minutes

Applicable ICD-10 CodesICD-10

C50.011	Malignant neoplasm of nipple and areola, right female breast.
C79.81	Secondary malignant neoplasm of breast.
C84.7A	Anaplastic large cell lymphoma, ALK-negative, breast.
D05.00	Lobular carcinoma in situ of unspecified breast.
I97.2	Postmastectomy lymphedema syndrome.
N65.0	Deformity of reconstructed breast.
Q79.8	Other congenital malformations of musculoskeletal system.
T85.43XA	Leakage of breast prosthesis and implant, initial encounter.
Z42.1	Encounter for breast reconstruction following mastectomy.
Z45.811	Encounter for adjustment or removal of right breast implant.

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Congenital Anomaly identification window

Identification windowCongenital anomaly is defined as a physical developmental defect present at birth and identified within the first twelve months of birth.

Definition sourceUnitedHealthcare Certificate of Coverage (COC, 2018) definition used in policy definitions.

Coverage implicationAnomalies identified after 12 months may not meet the policy's congenital-anomaly definition for reconstructive coverage consideration.

Provider Requirements, Prior Authorization, and Documentation

Note

Policy is informational — verify plan requirements

Before using this policy, verify federal, state, and contractual benefit plan requirements as those terms govern coverage and may differ from this policy. In the event of a conflict, federal, state, or contractual requirements take precedence. This policy is informational and does not constitute medical advice.

Check plan-specific coverage, limitations, and exclusions before submitting authorizations or claims.
In a conflict between this policy and plan/contract/federal or state law, follow the law or contract.

Prior Authorization

Verify potential use of third‑party criteria

UnitedHealthcare and Colorado Rocky Mountain Health Plans may use third-party clinical criteria (for example, InterQual®) to assist in coverage determinations. Providers should confirm whether third‑party criteria apply to the requested service.

InterQual CP: Procedures, Breast Reconstruction and InterQual CP: Procedures, Breast Implant Removal are commonly referenced.

Background and Clinical Context

Breast reconstruction restores breast appearance after lumpectomy or mastectomy for cancer and may be performed immediately at the time of oncologic surgery or delayed following adjuvant therapy (radiation or chemotherapy). Reconstruction is also indicated for congenital anomalies (for example, Poland or Turner syndromes) or severe disfigurement from radiation or trauma, and for implant removal in specified circumstances (including removal of certain textured implants). Related procedures — such as nipple/areola creation (including tattooing), mastopexy or reduction when required to preserve nipple viability before mastectomy, tissue expander use, and implantation of acellular dermal matrix — may be considered part of reconstructive care when performed with reconstructive intent.

Definitions and Key Terms

Acellular Dermal Matrix (ADM) — examples and definition

DefinitionAcellular Dermal Matrix (ADM) is a type of surgical mesh developed from human or animal skin in which the cells are removed and the support structure is left in place (FDA, 2021).

Examples named in policyAlloDerm, Cortiva, AlloMax, DermACELL, FlexHD are listed as ADM examples used with reconstruction.

Clinical useADM may be implanted for soft tissue reinforcement in implant-based breast reconstruction and tissue expander procedures.

Mastectomy — definition and types

DefinitionMastectomy is surgery to remove all or part of the breast; types differ by amount of tissue and lymph nodes removed.

Role in reconstructionReconstruction may be performed during or after mastectomy to restore breast appearance; reconstruction can be immediate or delayed.

Policy Revision History

2026-04-01template updateLatest

Template update removing content/language pertaining to the state of Louisiana.

2025-11-01supporting information update

Updated Clinical Evidence and References sections; previous policy version archived (CS011.V).

Policy history records a template update and supporting information updates. Recent entries note removal of Louisiana‑specific language and updates to Clinical Evidence and References; the supporting information and references were updated and the prior version archived.