Currentsierra health and lifePolicy MP.004.31

Breast Reduction Surgery

Policy governing coverage and medical necessity criteria for reduction mammaplasty (breast reduction) for UnitedHealthcare Commercial and Individual Exchange members, including applicability of the Women's Health and Cancer Rights Act and plan-specific exclusions.

Policy Summary

Payersierra health and life

PolicyBreast Reduction Surgery

Policy CodePolicy MP.004.31

Change TypeAdministrative update

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain prior authorization when billing CPT 19318 and document medical records to demonstrate InterQual® criteria and member benefit plan applicability.

SourceLink

POLICY UPDATE CHANGES

Created shared policy version to support application to Oxford plan membership.

Archived previous policy version MP.004.30 and SURGERY 032.37.

1CPT code listed

2Diagnosis codes

1998WHCRA year

01/01/2026Effective

Coverage Criteria and Policy Stance

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Medically Necessary and Plan-Dependent Coverage

Covered when ANY of the following conditions are met:

Coverage Conditions: Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances, covered when it qualifies under the Women's Health and Cancer Rights Act of 1998 OR when InterQual® reduction mammaplasty criteria are met and the member's plan allows treatment of physiologic functional impairment.

Refer to InterQual® CP: Reduction Mammaplasty (Female and Adolescent) and the member specific benefit plan for applicability.

Most UnitedHealthcare plans have a specific exclusion for breast reduction surgery except as required by the Women's Health and Cancer Rights Act of 1998; refer to the member specific benefit plan document for applicable coverage. When breast reduction meets the Act's requirements it is covered under all plans. In addition, breast reduction surgery is considered reconstructive and medically necessary in certain circumstances; medical necessity determinations use the InterQual® CP criteria for reduction mammaplasty (female and adolescent).

If a proposed breast reduction does not qualify under the Women's Health and Cancer Rights Act of 1998, coverage depends on the member's specific plan. Some plans may allow breast reduction when it is determined to treat a physiologic functional impairment, while other plans expressly exclude breast reduction even for physiologic impairment. Always consult the member specific benefit plan document to determine whether the plan allows coverage in these circumstances.

Prior Authorization, Documentation, and Review Process

Prior Authorization

Prior Authorization Required

Prior authorization is required. Verify member-specific benefit plan applicability before proceeding — many Sierra Health and Life (UnitedHealthcare) plans exclude breast reduction except as required by the Women’s Health and Cancer Rights Act (WHCRA) or when the benefit plan allows treatment of physiologic functional impairment.

Prior authorization required prior to scheduling.
Confirm WHCRA applicability or specific plan benefit for breast reduction.
If member has a gender dysphoria treatment benefit, coverage may follow that policy — see Gender Dysphoria Treatment policy.

Denial Risk

Denial may result when the member’s benefit plan explicitly excludes reduction mammaplasty or when the request fails to meet the InterQual® reduction mammaplasty medical necessity criteria.

Denial triggers: plan exclusion for breast reduction (unless WHCRA applies).
Denial triggers: failure to meet InterQual® Reduction Mammaplasty criteria (female or adolescent).
Inclusion of CPT/diagnosis codes in this guideline does not guarantee coverage or payment.

Documentation Required

Documentation Required for Review

Provide complete medical records to demonstrate medical necessity. Documentation is required for review and does not guarantee coverage; the member-specific benefit plan and applicable laws govern final coverage determinations.

Submit operative notes, preoperative evaluations, and clinical measurements (e.g., estimated tissue resection weight, symptoms attributable to breast hypertrophy).
Include prior conservative therapy documentation (e.g., physical therapy, analgesic use) and objective findings supporting functional impairment.
Attach relevant imaging, specialist consult notes, and any prior authorization forms or prior medical records requested.

Note

InterQual® Criteria and Benefit Verification

Use InterQual® clinical criteria for Reduction Mammaplasty (Female and Adolescent) to determine medical necessity. Also review member-specific benefit documents for exclusions and WHCRA rights prior to authorization decision.

Apply InterQual® Reduction Mammaplasty criteria during clinical review.
Verify member benefit plan for exclusions, WHCRA coverage, or gender dysphoria treatment benefit.
Applicable CPT: 19318. Applicable ICD-10: N62, N65.1 (reference only; inclusion does not imply coverage).

Clinical Background

Reduction mammaplasty (breast reduction) can be considered reconstructive and medically necessary in certain situations — for example when it qualifies under the Women's Health and Cancer Rights Act of 1998 or when clinical criteria for physiologic functional impairment are met. Medical necessity reviews reference the InterQual® CP: Reduction Mammaplasty (Female and Adolescent) to determine if the clinical requirements are satisfied; coverage is ultimately subject to the member's benefit plan terms.

Key Definitions and Legal References

Women's Health and Cancer Rights Act of 1998 — summary and applicability

Federal statuteWomen's Health and Cancer Rights Act of 1998 (29 U.S.C. § 1185b): requires group health plans and issuers that provide medical and surgical benefits for mastectomy to also provide coverage for (1) all stages of reconstruction of the breast on which the mastectomy was performed, (2) surgery and reconstruction of the other breast to produce a symmetrical appearance, and (3) prostheses and physical complications of mastectomy, including lymphedemas, in consultation with the attending physician and patient.

Applicability to group plans and issuersApplies to group health plans and health insurance issuers providing coverage in connection with a group health plan that provide mastectomy benefits.

Required scope of coverageIncludes coverage for all stages of breast reconstruction, contralateral surgery for symmetry, and related prostheses and treatment of physical complications of mastectomy (e.g., lymphedema).

Patient–physician consultationCoverage determinations for reconstruction, symmetry procedures, and related prostheses should be made in consultation with the attending physician and the patient.

OpenPayer

Breast Reduction Surgery

Coverage Criteria and Policy Stance

Referenced Procedure and Diagnosis Codes

Prior Authorization, Documentation, and Review Process

Clinical Background

Key Definitions and Legal References

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