CurrentColorado Rocky Mountain Health PlansPolicy MP.004.32

Breast Reduction Surgery (Reduction Mammaplasty) Coverage Criteria

Defines coverage and medical necessity criteria for breast reduction (reduction mammaplasty), including WHCRA-required reconstruction and InterQual guidance; applies to providers and members under commercial and individual exchange plans.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyBreast Reduction Surgery (Reduction Mammaplasty) Coverage Criteria

Policy CodePolicy MP.004.32

Change TypeRoutine reviewno coverage change

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionVerify member-specific benefits and obtain InterQual-based documentation for medical necessity prior to authorization submission.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

19318procedure code listed

N62, N65.1diagnosis codes

Commercial & Exchangeplan types governed

RequiredWHCRA coverage

InterQualclinical criteria source

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Coverage Criteria for Breast Reduction (Reduction Mammaplasty)

Medical necessity and WHCRA coverage

Covered when ALL of the following are met (policy-level guidance):

WHCRA-related reconstruction: Breast reduction/reconstruction performed in connection with a mastectomy is covered as required by the Women's Health and Cancer Rights Act of 1998

See statute for scope; payer states coverage for all stages of reconstruction and symmetry procedures.

Plans allowing reduction for functional impairment: Some plans may allow breast reduction when it treats a physiological functional impairment, if not excluded by the member specific benefit plan

Member specific benefit plan determines applicability; InterQual criteria guide medical necessity assessments.

Most UnitedHealthcare commercial and individual exchange plans include a specific exclusion for breast reduction surgery (reduction mammaplasty) except where coverage is required by the Women's Health and Cancer Rights Act of 1998 (WHCRA) or where a member specific benefit plan provides an allowance. Refer to the member specific benefit plan document to determine whether an exclusion applies. All plans cover breast reductions that qualify under WHCRA; if a procedure does not qualify under WHCRA, some plans may still allow coverage when the surgery is determined to treat a physiological functional impairment, while other plans may continue to exclude the service.

This policy underwent a routine review on 06/01/2026 with no change to coverage guidelines. The document does not list additional not-medically-necessary conditions beyond the plan-specific exclusions already described.

Coding

Procedure codes listedCPT

19318

Breast reduction.

Diagnosis codes referencedICD-10

N62	Hypertrophy of breast.
N65.1	Disproportion of reconstructed breast.

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization — Verify Plan and Provide InterQual-Based Documentation

Prior authorization is required. Verify the member's plan benefits and obtain prior authorization when applicable. Provide documentation that aligns with InterQual® criteria or other designated clinical criteria to support medical necessity.

Verify member-specific benefits and coverage before scheduling or performing services.
Submit InterQual-based documentation or equivalent clinical evidence with the prior authorization request.

Note

Provider Action — General

Providers should confirm benefit coverage, authorization requirements, and any documentation needed prior to delivering services. Contact the plan for questions about member benefits or authorization processes.

Check member-specific benefit plan for coverage details and exclusions.
Follow payer instructions for submission of authorization requests and supporting records.

Background

Breast reduction (reduction mammaplasty) is an operation performed to reduce breast size and may be considered reconstructive and medically necessary in specific situations, for example when performed in connection with a mastectomy or when it treats a physiological functional impairment. Coverage determinations for medical necessity reference InterQual® reduction mammaplasty criteria; when reconstruction is related to mastectomy, coverage is required under WHCRA. Refer to the member specific benefit plan and InterQual criteria for documentation and clinical threshold requirements.

Definitions

WHCRA — Women's Health and Cancer Rights Act of 1998

StatuteWomen's Health and Cancer Rights Act of 1998 (29 U.S.C. § 1185b)

Coverage requirementIf a group health plan provides medical and surgical benefits with respect to a mastectomy, the plan must provide coverage for breast reconstruction when a participant elects reconstruction in connection with the mastectomy.

Scope of reconstruction coverageIncludes all stages of reconstruction of the breast on which the mastectomy was performed.

Symmetry proceduresRequires coverage for surgery and reconstruction of the other breast to produce a symmetrical appearance.

Related servicesRequires coverage for prostheses and treatment of physical complications of mastectomy (including lymphedemas) as determined in consultation with the attending physician and patient.