Breast Reconstruction (for New Mexico Only)

Coverage Summary

UnitedHealthcare Medical Policy CS011NM.C (New Mexico) addresses breast reconstruction and defines circumstances considered reconstructive and medically necessary: reconstruction performed during or after mastectomy, reconstruction to treat congenital disorders (e.g., Poland syndrome, Turner syndrome), and reconstruction for severe breast disfigurement (e.g., amastia, radiation). Covered adjunct procedures include creation of the nipple and areola (including tattooing), mastopexy or breast reduction when required prior to mastectomy to preserve nipple viability, reconstruction with breast implant with or without tissue expander placement, and use of Acellular Dermal Matrix (ADM) in reconstruction.

The policy also covers treatment of complications after mastectomy (for example, lymphedema care including complex decongestive physiotherapy, lymphedema pumps and compression sleeves, treatment of postoperative infections, and related bandaging/wraps). Removal of breast implants is considered reconstructive and medically necessary in specified situations, including individuals implanted with Allergan BIOCELL textured implants due to increased risk of BIA-ALCL; removal may be with or without capsulectomy/capsulotomy per InterQual criteria. The policy lists cosmetic exclusions (procedures considered not medically necessary when not related to mastectomy), and specifies that coverage is state-specific to New Mexico and subject to applicable federal, state, or contractual requirements.

Clinical necessity determinations reference InterQual clinical criteria (Procedures: Breast Reconstruction; Breast Implant Removal) and the policy includes applicable CPT/HCPCS/ICD-10 codes and related definitions. Documentation requirements and other administrative provisions apply (see provider/prior authorization guidance); referenced code lists are provided for applicability/reference and should be verified for prior authorization and billing.

Key Facts

Policy numberCS011NM.C

Effective date2025-11-01

StatusCURRENT

SubjectBreast Reconstruction (New Mexico)

Scope summaryUnitedHealthcare New Mexico policy describing when breast reconstruction and related procedures (including nipple/areola creation, mastopexy, implants/expanders, ADM use), implant removal for Allergan BIOCELL textured implants, treatment of post‑mastectomy complications (e.g., lymphedema), and cosmetic exclusions are considered medically necessary or excluded.

Has material changetrue (Summary of Changes dated 11/01/2025 added Medical Records Documentation Used for Reviews and clarified that documentation does not guarantee coverage)

Medical Necessity Criteria

Medically Necessary Breast Reconstruction

Breast reconstruction is considered reconstructive and medically necessary when performed during or after mastectomy or for treatment of congenital disorder or severe breast disfigurement. Covered when ALL of the following are met:

ALL of the following

Indication: Procedure performed during or post mastectomy; OR for treatment of congenital disorder (e.g., Poland syndrome, Turner syndrome); OR for severe breast disfigurement (e.g., amastia, radiation)
Included reconstructive procedures: Reconstruction may include creation of nipple and areola (including tattooing), mastopexy or breast reduction when required prior to mastectomy to preserve nipple viability, reconstruction with breast implant (with or without tissue expander or use of Acellular Dermal Matrix)
FDA has not cleared ADMs specifically for breast reconstruction; see FDA communications

Coding (Referenced Codes)

Referenced CPT / Procedure Codes (applicable/reference)CPT

11920	Tattooing, intradermal... 6.0 sq cm or less
11921	Tattooing... 6.1 to 20.0 sq cm
11922	Tattooing... each additional 20.0 sq cm
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... first 25 sq cm or less
15272	Application of skin substitute graft... each additional 25 sq cm
15771	Grafting of autologous fat... 50 cc or less injectate
15772	Grafting of autologous fat... each additional 50 cc injectate
15777	Implantation of biologic implant (e.g., ADM) for soft tissue reinforcement

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Referenced HCPCS / Other Procedure CodesHCPCS

L8600	Implantable breast prosthesis, silicone or equal
S2066	Breast reconstruction with GAP flap, unilateral
S2067	Breast reconstruction with stacked DIEP/GAP flap(s), unilateral
S2068	Breast reconstruction with DIEP or SIEA flap, unilateral
S8950	Complex lymphedema therapy, each 15 minutes

Referenced ICD-10 Diagnosis Codes (applicable/reference)ICD-10

C50.011	Malignant neoplasm of nipple and areola, right female breast
C50.012	Malignant neoplasm of nipple and areola, left female breast
C50.019	Malignant neoplasm of nipple and areola, unspecified female breast
C50.021	Malignant neoplasm of nipple and areola, right male breast
C50.022	Malignant neoplasm of nipple and areola, left male breast
C50.029	Malignant neoplasm of nipple and areola, unspecified male breast
C50.111	Malignant neoplasm of central portion of right female breast
C50.112	Malignant neoplasm of central portion of left female breast
C50.119	Malignant neoplasm of central portion of unspecified female breast
C50.121	Malignant neoplasm of central portion of right male breast

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Codes listed in the policy are provided as applicable/reference and should be verified for prior authorization and billing purposes; inclusion in the policy does not guarantee coverage or reimbursement. Providers should confirm coding requirements for prior authorization and claim submission.

Note: the policy states that intraoperative assessment of vascular perfusion is considered an integral part of breast reconstruction and is not separately reimbursable (see provider actions / billing rules).

Provider Actions & Billing Rules

Unsupported block type: documentation

Unsupported block type: prior_auth

Unsupported block type: billing_rule

Unsupported block type: documentation

Unsupported block type: prior_auth

Background & Evidence

Breast reconstruction may be required after lumpectomy or mastectomy to restore appearance and can be performed immediately or delayed until completion of adjuvant therapy or patient decision. Reconstruction is also indicated for non-cancer conditions such as Poland syndrome, radiation- or trauma-related disfigurement, and for removal of implants with or without capsulectomy/capsulotomy.

Removal of Allergan BIOCELL textured implants is specifically considered medically necessary due to the increased risk of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL).

Acellular Dermal Matrix (ADM) products are commonly used in implant-based reconstruction, but the FDA has not cleared ADMs specifically for breast reconstruction and certain ADM products may have differing complication profiles; the policy references FDA communications on ADM safety.

Evidence and reference sources cited in the policy include InterQual clinical criteria (Procedures: Breast Reconstruction; Breast Implant Removal) as the clinical coverage reference tool; systematic reviews and randomized trials assessing ADM use and outcomes; multiple studies and reviews on nipple reconstruction techniques and outcomes; systematic reviews and cohort studies addressing BIA-ALCL epidemiology, risk, and management; and clinical guidance and society statements (for example, ASPS guidance and FDA communications).

Selected referenced study types: randomized controlled trials and RCT meta-analyses on ADM use, systematic reviews on nipple-areola reconstruction techniques, prospective cohort studies and systematic reviews on BIA-ALCL, and rehabilitation trials for lymphedema management.

Term	Definition
Acellular Dermal Matrix (ADM)	A type of surgical mesh developed from human or animal skin, in which the cells are removed, and the support structure is left in place (FDA, 2021).
Anaplastic Lymphoma	A rare type of non-Hodgkin lymphoma; breast implant-associated anaplastic large cell lymphoma most commonly presents as a delayed fluid collection around a textured implant or as a mass in the fibrous capsule surrounding the implant.
Congenital Anomaly	A physical developmental defect that is present at the time of birth and that is identified within the first twelve months of birth.
Mastectomy	Surgery to remove all or part of the breast; different types differ in the amount of tissue and lymph nodes removed.
Mastopexy/Breast Lift	A procedure that raises the breast, removes excess skin, and tightens surrounding tissue.

Revision History

2025-11-01material_changeLatest

Medical Records Documentation Used for Reviews: added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage; the patient's medical record must contain documentation fully supporting medical necessity (including relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures); documentation should be legible, maintained in the patient's medical record, and must be made available upon request.

2025-11-01supporting_information_update

Supporting Information updated: Clinical Evidence and References sections updated to reflect the most current information; previous policy version CS011NM.B archived.