CurrentUnitedHealthcarePolicy CS012NJ.U

Breast Reduction Surgery (for New Jersey Only)

UnitedHealthcare medical policy applying only to New Jersey members that defines coverage rationale for breast reduction (reduction mammaplasty) and references InterQual criteria for clinical medical necessity. Includes applicable CPT and ICD-10 codes for reference and notes related policies.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reduction Surgery (for New Jersey Only)

Policy CodePolicy CS012NJ.U

Change TypeRelated policies and codes updated; new version published

Effective DateJun 1, 2025

Next Review Date

Key ActionProviders must demonstrate that the patient meets the InterQual CP: Procedures criteria for Reduction Mammaplasty (Female) or Reduction Mammaplasty (Female, Adolescent) when requesting coverage.

POLICY UPDATE CHANGES

Related Policies and Applicable Codes updated; reference link to Panniculectomy and Body Contouring Procedures (for New Jersey Only) removed.

Policy version CS012NJ.U effective June 1, 2025 created and replaces archived CS012NJ.T.

1Primary CPT referenced

2Referenced ICD-10 codes

Coverage Summary

Breast reduction surgery (reduction mammaplasty) is considered reconstructive and may be medically necessary in certain circumstances. This policy applies only to New Jersey members. UnitedHealthcare uses the proprietary clinical criteria tool InterQual CP: Procedures (Reduction Mammaplasty, Female and Reduction Mammaplasty, Female, Adolescent) to determine medical necessity.

Medical Necessity Criteria (referenced)

Coverage depends on meeting InterQual CP: Procedures criteria for Reduction Mammaplasty (Female) or Reduction Mammaplasty (Female, Adolescent):

Medical Necessity Criteria (referenced): Member meets InterQual CP: Procedures - Reduction Mammaplasty, Female OR InterQual CP: Procedures - Reduction Mammaplasty, Female, Adolescent

InterQual criteria contain the specific clinical thresholds and documentation requirements (e.g., symptoms, failed conservative therapy, resection weight/volume or functional impairment) used to determine medical necessity

InterQual is a proprietary clinical criteria tool used by UnitedHealthcare to determine medical necessity for procedures. InterQual contains specific thresholds and documentation requirements — for reduction mammaplasty these include resection weight/volume, symptoms, failed conservative therapy, and functional impairment as part of the criteria used to determine medical necessity.

Referenced Codes

Referenced CPT codesCPT

19318

Breast reduction

Referenced ICD-10 diagnosis codesICD-10

N62	Hypertrophy of breast
N65.1	Disproportion of reconstructed breast

Listed diagnostic codes do not by themselves guarantee coverage. Providers must report CPT code 19318 for breast reduction (reduction mammaplasty) as appropriate and must demonstrate that the patient meets the InterQual CP: Procedures criteria when requesting coverage.

Provider Actions

Documentation Required

Use InterQual criteria for medical necessity determination

Providers must demonstrate that the patient meets the InterQual CP: Procedures criteria for Reduction Mammaplasty (Female) or Reduction Mammaplasty (Female, Adolescent) when requesting coverage; InterQual contains the detailed clinical thresholds and required documentation.

19318

Billing Rule

Code reporting

Report CPT code 19318 for breast reduction (reduction mammaplasty) as appropriate; listed diagnosis codes N62 and N65.1 are provided for reference but do not by themselves guarantee coverage.

19318
N62
N65.1

Background

Breast reduction (reduction mammaplasty) is described as reconstructive and may be medically necessary in certain circumstances. UnitedHealthcare references the proprietary clinical criteria tool InterQual (CP: Procedures - Reduction Mammaplasty, Female and Reduction Mammaplasty, Female, Adolescent) to establish the clinical thresholds and documentation required to determine medical necessity. This policy is applicable only to New Jersey members.

Revision History

06/01/2025revised

Related Policies and Applicable Codes updated; reference link to Panniculectomy and Body Contouring Procedures (for New Jersey Only) removed. Supporting Information archived previous policy version CS012NJ.T.

June 1, 2025addedLatest