CurrentUnitedHealthcarePolicy BIP176.N

Post Mastectomy Surgery / Breast Reconstruction Coverage

Defines mandated coverage requirements and related guidance for post-mastectomy surgery, prosthetic devices, and reconstructive surgery (including symmetry procedures) applicable to UnitedHealthcare West members; references applicable federal and California state statutes and related UnitedHealthcare policies.

Policy Summary

PayerUnitedHealthcare

PolicyPost Mastectomy Surgery / Breast Reconstruction Coverage

Policy CodePolicy BIP176.N

Change TypeRevised (statutory reference updated)

Effective DateJan 1, 2026

Next Review Date

Key ActionDetermine hospital length of stay after mastectomy by the attending physician and surgeon in consultation with the patient (no prior plan approval).

SourceLink

POLICY UPDATE CHANGES

Revised language pertaining to the California Health and Safety Code (HSC) Section 1367.635 Supporting Information.

1policy revision recorded on 01/01/2026

CA HSC 1367.635state statute explicitly cited and summarized

WHCRAfederal statute referenced

NoneState Market Plan Enhancements

Coverage Criteria

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Statutory mandated coverage

Covered when ALL of the following statutory conditions are met:

Statutory coverage requirements: (1) Coverage for screening, diagnosis, treatment, and reconstructive surgery/prosthetic devices incident to mastectomy as required by the federal Women's Health and Cancer Rights Act (WHCRA) and California Health and Safety Code (HSC) sections 1367.6 and 1367.635; (2) Initial and subsequent reconstructive surgeries and prosthetic devices are covered when deemed necessary by the attending physician and surgeon ("coverage for prosthetic devices or reconstructive surgery" includes any initial and subsequent reconstructive surgeries or prosthetic devices and follow‑up care deemed necessary); (3) Coverage includes procedures and prosthetic devices to restore and achieve symmetry of the contralateral healthy breast when, in the opinion of the attending physician and surgeon, such procedures are necessary to achieve a normal symmetrical appearance; (4) Coverage includes treatment of all complications from a mastectomy, including lymphedema; (5) The length of hospital stay associated with mastectomy and lymph node dissection shall be determined by the attending physician and surgeon in consultation with the patient, and the plan shall not require prior approval for that determination; (6) Coverage for prosthetic devices and reconstructive surgery is subject to the member's applicable deductible, coinsurance, copayment, and other terms and conditions in the Evidence of Coverage/Schedule of Benefits; (7) No individual other than a licensed physician and surgeon competent to evaluate the clinical issues may deny authorization requests related to these services; (8) Notices of this coverage are to be included in the plan's Evidence of Coverage on or after the dates required by statute.

None specified in this policy.

No specific non-medically necessary conditions are described in this policy. All services must be medically necessary and coverage is subject to the specific provisions, limitations, and exclusions in the member's Evidence of Coverage (EOC)/Schedule of Benefits (SOB); when the policy and a member's EOC/SOB conflict, the member's EOC/SOB governs.

Coding and Hospital Stay

Referenced Policies/Guidance (no specific CPT/ICD codes listed)mixed

No codes listed

Hospital stay determination — Length determined by attending physician/surgeon in consultation with patient.

Policy requirementLength of hospital stay after mastectomy shall be determined by the attending physician and surgeon in consultation with the patient, consistent with sound clinical principles; the plan shall not require prior approval for that determination.

ScopeApplies to health care service plan contracts issued, amended, renewed, or delivered on or after January 1, 1999 that provide coverage for mastectomies and lymph node dissections.

Clinical standardDetermination must be made postsurgery by the attending physician and surgeon in consultation with the patient.

Plan limitationNo health care service plan shall require a treating physician and surgeon to receive prior approval from the plan in determining the length of hospital stay following these procedures.

Provider Actions and Authorization

Prior Authorization

Prior Authorization for Post‑Mastectomy Stay

Length of hospital stay following mastectomy shall be determined by the attending physician and surgeon in consultation with the patient, consistent with sound clinical principles and processes. The plan shall not require prior approval from the plan for determining the length of stay following mastectomy.

Applies to mastectomy and lymph node dissection hospital stays
Member-facing decision made by attending physician and surgeon in consultation with patient
No prior authorization required for length of post-mastectomy hospital stay

Denial Risk

Authorization Denial Limitation

Requests for authorization must not be denied by persons other than a licensed physician and surgeon competent to evaluate the specific clinical issues involved in the care requested.

Only a licensed physician and surgeon competent in the specific clinical issues may deny authorization requests

Step Therapy

No step therapy guidance is applied for the services addressed by this section.

Step therapy: not applicable

Background

Mastectomy is understood to include removal of all or part of the breast for medically necessary reasons; coverage extends to reconstructive surgery and provision of prosthetic devices incident to the mastectomy, as well as procedures to restore symmetry of the contralateral breast when the attending surgeon deems them necessary. Coverage and any applicable limits, deductibles, or coinsurance are determined by the member's plan and EOC/SOB. Requests for services must meet medical necessity criteria outlined in the member's coverage documents.

Definitions

Mastectomy — definition

Definition"Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon.

IncludesPartial removal examples include lumpectomy (surgical removal of the tumor with clear margins).

Clinical determinationMedically necessary indication and determination are to be made by a licensed physician and surgeon.

Restore and achieve symmetry — reconstructive surgery or prosthetic devices for the healthy breast

Restore and achieve symmetryIncludes reconstructive surgery or prosthetic devices for the healthy (contralateral) breast when, in the opinion of the attending physician and surgeon, such surgery or devices are necessary to achieve normal symmetrical appearance.

Coverage linkageCoverage for reconstructive surgery and prosthetic devices to achieve symmetry is incident to the mastectomy and subject to applicable deductible and coinsurance conditions.

Clinical authorityDecision that symmetry procedures are necessary must be made by the attending physician and surgeon.

Prosthetic devices — provision of initial and subsequent devices per physician order

Definition"Prosthetic devices" means and includes the provision of initial and subsequent prosthetic devices pursuant to an order of the patient's physician and surgeon.

Scope of coverageCoverage includes any initial and subsequent prosthetic devices and follow-up care deemed necessary by the attending physician and surgeon.

Order requirementProvision of prosthetic devices must be pursuant to a physician and surgeon's order.