General coverage rule: Procedure is recommended by the member's primary care physician or referring surgeon, is reasonably expected to resolve the medical condition or functional impairment, and meets the medical necessity criteria indicated (including InterQual where referenced)
Mass General Brigham may deny procedures that are cosmetic or not in accordance with WHCRA.
Cancer-related indications: Mastectomy or lumpectomy for cancer or cancer-related prophylaxis (including prophylactic mastectomy for BRCA or other defined genetic predisposition); reconstruction following mastectomy/lumpectomy including symmetry surgery, prostheses, treatment of physical complications at all stages, and areola tattooing
Per WHCRA coverage requirements (see regulation).
Gender-affirming indications: Medically necessary mastectomy or breast augmentation mammoplasty for gender incongruence (dysphoria) when the member meets relevant medical necessity criteria under the Gender Affirming Procedures policy
Prior authorization required when indicated by the policy.
Other medical indications: Severe disfigurement from congenital chest wall deformities (e.g., Poland syndrome, amazia) or repair of severe asymmetry from injury, burns, or trauma
Photo documentation is required for reconstruction related to other medical conditions.
Reduction mammoplasty (female): Medical necessity determined by InterQual criteria customized by Mass General Brigham Health Plan, including requirement for photo documentation, member age assessment (members <18 eligible when Tanner stage V, typically ≥15), and mammogram requirements for women aged 50 or olderNegative mammogram within 2 years for women ≥50
Coverage limited to one reduction mammoplasty procedure per member per lifetime; see InterQual customizations for additional thresholds (e.g., Schnur table).
Reduction mammoplasty (male/gynecomastia): Medical necessity determined by InterQual criteria customized by Mass General Brigham Health Plan; photo documentation is required
Surgical treatment is not considered medically necessary for gynecomastia due to illicit substance use, alcohol use disorder, non‑prescribed supplements/hormones, or pseudogynecomastia.
Breast implant removal and capsular procedures: Medical necessity determined by InterQual criteria customized by Mass General Brigham Health Plan; covered indications include implant infection, extrusion, identified or suspected rupture (imaging-identified or suspected on exam with localized pain, contour change, or size change), and capsular contracture (Baker Class III with localized pain)
See exclusions for implants placed solely for cosmetic purposes and for other NMN conditions.
Nipple surgery/repair: Covered when documentation shows an inverted nipple causing inability to breastfeed and the procedure is reasonably expected to restore function; or when inversion causes chronic bleeding, discharge, scabbing, or infection; or when performed as part of an authorized breast reconstruction (including areola tattooing)