Breast Reduction Surgery (for Ohio Only)
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This policy governs coverage and medical necessity evaluation for reduction mammaplasty requests for members in Ohio and applies to requests evaluated under Ohio Administrative Code 5160-1-01.
Medical Records Documentation Used for Reviews section added language specifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess medical necessity.
Detailed list of what medical record documentation must contain (relevant medical history, physical exam, results of diagnostic tests) and that documentation should be legible and available upon request.
References section updated to reflect most current Ohio Administrative Code citation.
Coverage and Medical Necessity Criteria
Medically Necessary (Reconstructive) Criteria
Covered when ALL applicable InterQual CP criteria for reduction mammaplasty (female or adolescent) are met.
UnitedHealthcare uses InterQual as primary medical/surgical criteria; if InterQual does not apply, other UnitedHealthcare policies/guidelines approved by Ohio Medicaid may be used.
For reduction mammaplasty requests related to gynecomastia, refer to the separate Gynecomastia Surgery (for Ohio Only) medical policy.
The list of procedure and diagnosis codes included in this policy is provided for reference only. Listing a code does not imply that the service described by the code is covered or guarantee reimbursement; benefit coverage is determined by federal, state, or contractual requirements and applicable law.
CPT and Diagnosis Codes (Reference)
| 19318 | Breast reduction |
| N62 | Hypertrophy of breast |
| N65.1 | Disproportion of reconstructed breast |
Provider Requirements, Prior Authorization, and Documentation
InterQual-driven prior authorization required
Requests for breast reduction (e.g., CPT 19318) require prior authorization and must meet the InterQual CP: Reduction Mammaplasty (Female) or InterQual CP: Reduction Mammaplasty (Female - Adolescent) medical necessity criteria as applicable; prior authorization evaluation will use those InterQual criteria.
- Example procedure code: CPT 19318 (listed for reference in policy applicable codes).
Follow this Ohio-specific policy and effective date
This policy applies to Breast Reduction Surgery (for Ohio Only) and is effective 08/01/2026; ensure requests and documentation follow the policy's medical necessity and documentation requirements and reference InterQual criteria for clinical decision-making.
- Policy identifier: CS012OH.E, effective 2026-08-01.
- Use InterQual CP: Reduction Mammaplasty (Female) or (Adolescent) when evaluating requests.
Required medical record elements
Patient medical record must contain legible documentation supporting medical necessity, including relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures; records must be made available upon request.
- Documentation should be maintained in the patient's medical record and be legible.
- Include history, exam findings, and diagnostic test/procedure results that demonstrate the member meets InterQual criteria.
Denial risk if documentation insufficient
Failure to provide medical record documentation that fully supports medical necessity (including relevant history, physical exam, and diagnostic test results) may result in denial or inability to approve requested services.
- Medical records may be requested to assess whether the member meets clinical criteria; providing records does not guarantee coverage.
- Incomplete or illegible documentation increases risk of denial or non-coverage.
Background and Clinical Context
Reduction mammaplasty (breast reduction) is performed to relieve symptoms and improve function when breast hypertrophy causes physical symptoms. This policy treats breast reduction as reconstructive and medically necessary in certain circumstances, and medical necessity is determined using the InterQual® CP criteria for Reduction Mammaplasty (Female) or Reduction Mammaplasty (Female - Adolescent) as applicable.
Key Definitions
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