Currentsierra health and lifePolicy MP.003.29

Breast Reconstruction

Medical policy for breast reconstruction procedures, related services, and complications following mastectomy or for certain congenital disorders and severe breast disfigurement; applies to UnitedHealthcare Commercial and Individual Exchange benefit plans and their members.

Policy Summary

Payersierra health and life

PolicyBreast Reconstruction

Policy CodePolicy MP.003.29

Change TypeTemplate update / shared policy version

Effective DateJanuary 1, 2026

Next Review Date

Key ActionObtain prior authorization and verify member-specific benefits and documentation before proceeding with reconstructive breast procedures.

SourceLink

POLICY UPDATE CHANGES

Created shared policy version to support application to Oxford plan membership and archived previous policy versions MP.003.28 and SURGERY 095.31.

MP.003.29Policy identifier

Jan 1, 2026Effective date

CPT/HCPCS/ICD-10Includes code lists

UnitedHealthcare Commercial & ExchangeApplicable plans

129 moMean event-free time to BIA-ALCL

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

01/01/2026Policy history date

Coverage Criteria and Indications

Covered indications and services

Covered when criteria described below are met:

Indications for reconstructive coverage: Breast reconstruction is covered after mastectomy with or without a diagnosis of cancer per the Women's Health and Cancer Rights Act of 1998, and for treatment of congenital disorders (e.g., Poland syndrome, Turner syndrome) or severe breast disfigurement (e.g., amastia, radiation) in certain circumstances.

Refer to InterQual CP: Procedures, Breast Reconstruction for medical necessity clinical coverage criteria.

Procedures considered reconstructive when performed with breast reconstruction: Creation of a nipple and areola (including tattooing); mastopexy or breast reduction when required prior to mastectomy to preserve nipple viability; reconstruction with a breast implant, including implantation of a tissue expander as the initial phase and use of an acellular dermal matrix (ADM).

Complications treatment covered: Treatment for post-mastectomy complications is covered when medically necessary, including lymphedema care (complex decongestive physiotherapy; lymphedema pumps as durable medical equipment; compression sleeves as prosthetic devices; elastic bandages/wraps) and post-operative infections.

Implant removal coverage: 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 due to increased risk of breast implant–associated ALCL; removal may be with or without capsulectomy/capsulotomy in certain circumstances.

Refer to InterQual CP: Procedures, Breast Implant Removal for clinical criteria.

Inverted nipple repair coverage: Repair or reconstruction of inverted nipples (not post-mastectomy) is considered reconstructive and medically necessary when there is documented chronic nipple discharge, bleeding, scabbing, or ductal infection, OR when the inversion results from a congenital anomaly.

Reconstructive procedures covered

Covered when services are reconstructive and medically necessary as described:

Reconstructive coverage per WHCRA and benefit considerations: Coverage includes reconstruction of the breast after mastectomy; reconstruction of the contralateral breast for symmetry (including nipple tattooing); prosthesis (implanted and/or external); treatment of physical complications of mastectomy (including lymphedema); and treatment of Poland syndrome with breast reconstruction.

Applies with or without diagnosis of cancer per the Women's Health and Cancer Rights Act of 1998.

Cosmetic exclusions

Procedures considered cosmetic and excluded (not covered) when not related to mastectomy or not restoring physiologic function:

Cosmetic exclusions: Procedures considered cosmetic and excluded include: aberrant breast tissue procedures; aspirations; biopsy (open or core); duct lesions; excision of cysts; fibroadenomas or other benign tumors; nipple or areolar lesions; treatment of gynecomastia; revision of a prior reconstructed breast for normal aging; tissue protruding at the end of a scar ('dog ear') unless painful or meeting reconstructive definition; breast enhancement (e.g., breast implants, mastopexy); liposuction; and breast surgery performed solely to create symmetric breasts when not related to mastectomy. Procedures that correct a congenital anatomical anomaly without improving or restoring physiologic function are also considered cosmetic and excluded.

These items are explicitly listed as cosmetic exclusions in Benefit Considerations.

Breast reconstruction performed solely to correct asymmetry—except when it meets reconstructive indications tied to mastectomy, congenital anomalies that restore physiologic function, or other covered reconstructive reasons—is considered cosmetic and not medically necessary.

Examples of procedures that are considered breast enhancement and therefore cosmetic when not related to mastectomy or other reconstructive indications include placement of breast implants, mastopexy (breast lift), and liposuction of the breast; these services are excluded from coverage when performed for cosmetic purposes.

Always verify coverage against the member specific benefit plan document; if plan terms conflict with this Medical Policy, the member specific benefit plan governs, and providers should obtain authorization per that plan’s rules.

Restatement: Breast reconstruction performed for asymmetry for indications other than covered reconstructive reasons is cosmetic and not medically necessary. Refer to the Benefit Considerations for reconstructive exceptions (e.g., post-mastectomy reconstruction, congenital conditions when restoring function).

Cosmetic exclusions listed in this policy are not medically necessary when performed for cosmetic purposes and are not related to mastectomy or to restoring physiologic function (for example, procedures that only create symmetry or correct appearance without functional benefit).

Procedure and Diagnosis Codes

Applicable CPT codes (selection)CPT

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).

Applicable CPT codes (reconstruction/flap/implant)CPT

19316	Mastopexy.
19325	Breast augmentation with implant.
19328	Removal of intact breast implant.
19330	Removal of ruptured breast implant, including implant contents (e.g., saline, silicone gel).
19340	Insertion of breast implant on same day of mastectomy (i.e., immediate).
19342	Insertion or replacement of breast implant on separate day from mastectomy.
19350	Nipple/areola reconstruction.
19355	Correction of inverted nipples.
19357	Tissue expander placement in breast reconstruction, including subsequent expansion(s).
19361	Breast reconstruction; with latissimus dorsi flap.

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Applicable HCPCS/S 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 diagnosis codes (selection)ICD-10

C50.011	Malignant neoplasm of nipple and areola, right female breast.
C50.012	Malignant neoplasm of nipple and areola, left female breast.
C84.7A	Anaplastic large cell lymphoma, ALK-negative, breast.
D05.11	Intraductal carcinoma in situ of right breast.
I97.2	Deformity of reconstructed breast.
N65.1	Disproportion 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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Applicable ICD-10 Codes — malignant, in situ, and deformity codesICD-10

C50.911	Malignant neoplasm of unspecified site of right female breast.
C50.912	Malignant neoplasm of unspecified site of left female breast.
C50.919	Malignant neoplasm of unspecified site of unspecified female breast.
C50.921	Malignant neoplasm of unspecified site of right male breast.
C50.922	Malignant neoplasm of unspecified site of left male breast.
C50.929	Malignant neoplasm of unspecified site of unspecified male 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.
D05.01	Lobular carcinoma in situ of right breast.

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Applicable ICD-10 and encounter codes — reconstruction, implant complications, congenitalICD-10

N65.1	Disproportion of reconstructed breast.
Q79.8	Other congenital malformations of musculoskeletal system.
T85.43XA	Leakage of breast prosthesis and implant, initial encounter.
T85.43XD	Leakage of breast prosthesis and implant, subsequent encounter.
T85.43XS	Leakage of breast prosthesis and implant, sequela.
Z42.1	Encounter for breast reconstruction following mastectomy.
Z45.811	Encounter for adjustment or removal of right breast implant.
Z45.812	Encounter for adjustment or removal of left breast implant.
Z45.819	Encounter for adjustment or removal of unspecified breast implant.
Z85.3	Personal history of malignant neoplasm of breast.

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Skin substitute graft wound area — billing thresholds (15271, 15272)

CPT codes15271 — Application of skin substitute graft: first 25 sq cm or less (first 25 sq cm)

Additional unit15272 — Application of skin substitute graft: each additional 25 sq cm wound surface area (listed separately in addition to primary procedure)

ScopeApplies to skin substitute grafts to trunk, arms, legs with total wound surface area up to 100 sq cm per code descriptors

Autologous fat graft injectate — billing thresholds (15771, 15772)

Primary injectate allowance15771 — Grafting of autologous fat; 50 cc or less injectate

Provider Responsibilities, Authorization, and Documentation

Billing Rule

Prior Authorization and Coding Note

Prior authorization and coding: Intraoperative assessment of vascular perfusion during breast reconstruction is considered an integral part of the primary procedure and is not separately billable. Providers should follow payer-specific coding guidance and obtain any required prior authorizations per plan rules before scheduling the procedure.

Integral procedure — do not bill separately for intraoperative vascular perfusion assessment
Obtain prior authorization when required by the member's plan

Prior Authorization

Authorization and Benefit Verification

Authorization and benefit verification: Coverage is determined by the member-specific benefit plan document. Providers must verify eligibility, benefits, prior authorization requirements, and any plan limits before providing services.

Clinical Background and Scope

Background: Breast reconstruction is typically performed after mastectomy (including for cancer) and may also be performed for certain congenital disorders or severe disfigurement; reconstructive approaches include implants, tissue expanders, flap procedures, nipple/areola creation (including tattooing), and use of acellular dermal matrices.

Definitions and Terms

Acellular Dermal Matrix (ADM) — definition and clinical context

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

PurposeUsed for soft tissue reinforcement in breast reconstruction (implantation of biologic implant, e.g., ADM; see CPT 15777)

ContextADM may be used with tissue expanders or implants as part of reconstructive procedures following mastectomy or to address breast deformity

Anaplastic Lymphoma — definition and BIA‑ALCL context

DefinitionAnaplastic Lymphoma: a rare subtype of T‑cell non‑Hodgkin lymphoma (NHL)

BIA‑ALCL presentationBreast implant‑associated ALCL most commonly presents as delayed fluid collection (seroma) around a textured implant or as a mass in the fibrous capsule

Policy Summary

Payersierra health and life

PolicyBreast Reconstruction

Policy CodePolicy MP.003.29

Change TypeTemplate update / shared policy version

Effective DateJanuary 1, 2026

Next Review Date

Key ActionObtain prior authorization and verify member-specific benefits and documentation before proceeding with reconstructive breast procedures.

SourceLink

On This Page

Additional volume15772 — Grafting of autologous fat; each additional 50 cc injectate (list separately in addition to primary procedure)

Anatomic sitesCodes apply to grafting to trunk, breasts, scalp, arms, and/or legs as described in code set

Mean event-free time to BIA-ALCL

Mean event-free time (EFT)129 months — mean EFT to development of BIA-ALCL reported in Santanelli et al. systematic review

Study contextSantanelli et al. analyzed 248 cases across multiple countries and reported mean EFT of 129 months

ImplicationLong latency supports need for extended surveillance after implantation, particularly with textured implants

Verify eligibility and benefits prior to scheduling
Request prior authorization per the member's plan when indicated

Note

Policy Is Interpretive — Verify Benefits

Policy is interpretive — verify benefits: This medical policy is provided to assist interpretation of standard benefit plans and does not replace the member-specific benefit plan document. In case of any conflict, the member-specific benefit plan governs.

Reference the member-specific benefit plan document for final coverage determinations
Confirm applicability of federal or state mandates that may affect coverage

Documentation Required

Medical Records — Documentation Requirement Risk

Medical records and documentation risk: Medical records documentation may be required to determine whether the member meets clinical coverage criteria. Failure to provide required documentation may result in denial of coverage.

Maintain and submit complete medical records to support medical necessity
Incomplete or missing documentation may lead to claim denial

Denial Risk

Cosmetic Exclusion Triggers

Cosmetic exclusion triggers: Procedures that correct an anatomical congenital anomaly without improving or restoring physiologic function, and other listed cosmetic procedures not related to mastectomy, are considered cosmetic and excluded from coverage. Examples include breast enhancement, liposuction, and procedures performed solely for asymmetry unrelated to reconstruction after mastectomy.

Excluded when not restoring physiologic function: aberrant breast tissue, aspirations, biopsy, duct lesions, excision of cysts, fibroadenomas, nipple/areolar lesions
Also excluded when not related to mastectomy: breast enhancement (e.g., implants, mastopexy), liposuction, breast surgery solely for symmetry

Note

Check Member-Specific Benefits

Check member-specific benefits: The member-specific benefit plan document must be referenced because terms, coverage, limitations, and exclusions may differ from the standard policy. In the event of a conflict, the member-specific plan governs.

Confirm benefits, limitations, exclusions, and timeline requirements in the member's plan
Apply federal/state mandates and plan-specific rules as applicable

Prior Authorization

Benefit Documentation and Gap Exception

Benefit documentation and gap exception: Providers should refer to the member-specific plan for required documentation. A gap exception may be granted if no in-network provider is able to provide the requested reconstructive procedure.

Submit documentation required by the member's plan to support a gap exception request
If no in-network provider is available, follow plan procedures to request a gap exception prior to scheduling

Epidemiology noteComprises a small percentage of T‑cell lymphomas and non‑Hodgkin lymphomas overall; clinical vigilance advised for implant patients

Congenital Anomaly — definition (identified within first 12 months)

DefinitionCongenital Anomaly: a physical developmental defect present at birth and identified within the first twelve months of birth (COC, 2018)

Coverage relevanceCertain congenital anomalies (e.g., Poland syndrome) can be indications for reconstructive breast surgery under this policy

Exclusion caveatProcedures correcting congenital anomalies that do not restore physiologic function may be considered cosmetic and excluded

Mastectomy — definition and variants

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

VariantsIncludes procedures performed for cancer treatment (e.g., total, partial, radical mastectomy) and may be followed by immediate or delayed reconstruction

Coverage linkReconstruction following mastectomy is covered per WHCRA and policy criteria; reconstruction may be immediate or delayed depending on adjuvant therapy

Mastopexy / Breast Lift — definition

DefinitionMastopexy/Breast Lift: procedure that raises the breast, removes excess skin, and tightens surrounding tissue (ASPS, 2022)

Role in reconstructionMastopexy may be performed on the contralateral breast for symmetry as part of reconstructive care following mastectomy

DistinctionWhen performed solely for aesthetic enhancement and not related to reconstruction or physiologic restoration, mastopexy is considered cosmetic and excluded

Reconstructive breast surgery — examples

Examples of proceduresReconstructive breast surgery may include mastopexy, implant- or autologous-based reconstruction, and nipple/areola reconstruction (including tattooing)

IndicationsPerformed after lumpectomy or mastectomy, for congenital disorders (e.g., Poland syndrome), radiation- or trauma-related disfigurement, or implant removal with/without capsulectomy

ScopeMay be immediate or delayed depending on patient therapy and preferences; includes treatment of physical complications of mastectomy (e.g., lymphedema) when medically necessary

BIA‑ALCL — brief definition

Brief definitionBIA‑ALCL: a T‑cell non‑Hodgkin lymphoma that can develop around breast implants, more commonly associated with textured implant surfaces

Clinical featuresOften presents with late seroma (delayed fluid collection) or as a mass in the fibrous capsule surrounding the implant

Management noteWhen confined to fluid and/or capsule, surgical removal of implant and complete capsulectomy is preferred; refer to oncology for staging and management

BIA‑ALCL — referenced guideline sources

Referenced professional sourcesAmerican Society of Plastic Surgeons (ASPS) guidance on diagnosis and treatment of BIA‑ALCL (ASPS, 2022)

Oncology guidanceNCCN and ASPS consensus statements and society publications (e.g., Clemens et al., NCCN consensus) are cited for diagnostic and treatment recommendations

Evidence baseSystematic reviews and cohort studies (e.g., Clemens et al., Cordeiro et al., Santanelli et al.) are referenced for risk, presentation, and management data