CurrentUnitedHealthcarePolicy CSNC.MP.004.06

Breast Reduction Surgery (North Carolina)

UnitedHealthcare medical policy applicable only to North Carolina that refers to North Carolina Medicaid Clinical Coverage Policy Physician: 1A-12 for medical necessity criteria for breast reduction surgery. Lists applicable CPT and ICD-10 codes for reference and contains revision history and related policies.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reduction Surgery (North Carolina)

Policy CodePolicy CSNC.MP.004.06

Change TypeAdministrative / Reference update

Effective DateJun 1, 2025

Next Review Date

Key ActionProviders must refer to and document compliance with North Carolina Medicaid Clinical Coverage Policy Physician: 1A-12 (Breast Surgeries) when requesting coverage for breast reduction surgery in North Carolina.

SourceLink

POLICY UPDATE CHANGES

06/01/2025 - Routine review; no change to coverage guidelines; archived previous policy version CSNC.MP.004.05.

11/01/2025 - Updated reference link to reflect the current policy title for Panniculectomy Surgery (for North Carolina Only).

1Primary CPT code listed

2ICD-10 diagnosis codes listed

1Referential clinical coverage policy

Coverage Summary

This UnitedHealthcare Medical Policy (Policy Number: CSNC.MP.004.06) applies only in the state of North Carolina and defers to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Physician: 1A-12 (Breast Surgeries) for determination of medical necessity for breast reduction surgery. Effective date: June 1, 2025; Last review / most recent revision noted: November 1, 2025.

Key Facts

Policy NumberCSNC.MP.004.06

ScopeUnitedHealthcare medical policy applicable only to North Carolina that refers to North Carolina Medicaid Clinical Coverage Policy Physician: 1A-12 for medical necessity criteria for breast reduction surgery. Lists applicable CPT and ICD-10 codes for reference and contains revision history and related policies.

Effective Date2025-06-01

Last Review2025-11-01

Coverage Stancemixed

Medical Necessity / Coverage Basis

Coverage Basis / Medical Necessity Reference

Coverage and medical necessity are determined by meeting the North Carolina Medicaid Clinical Coverage Policy Physician: 1A-12 criteria. This policy defers to that policy for clinical coverage criteria:

State and Coverage: Patient is covered under UnitedHealthcare in the state of North Carolina
Medical Necessity Determination: Medical necessity for breast reduction is determined by North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Physician: 1A-12, Breast Surgeries (refer to that document for specific criteria)

Reference Link: Refer to North Carolina Medicaid, Division of Health Benefits, Physician Clinical Coverage Policies, Breast Surgeries, 1A-12 for full clinical criteria

Specific numeric thresholds, clinical criteria, and detailed eligibility requirements for medical necessity of breast reduction are contained in the referenced source: the North Carolina Medicaid Clinical Coverage Policy Physician: 1A-12 (Breast Surgeries), which this UnitedHealthcare policy directs users to follow for North Carolina members.

Provider Actions & Documentation

Documentation Required

Apply North Carolina Medicaid Clinical Coverage Policy criteria

Refer to and document compliance with the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Physician: 1A-12 (Breast Surgeries) when requesting coverage for breast reduction surgery in North Carolina. Include specific references to the NC Medicaid Clinical Coverage Policy 1A-12 in the member’s medical record to demonstrate that the criteria were reviewed and met.

19318
N62
N65.1

Background

Background: This UnitedHealthcare policy applies only in North Carolina and defers to the North Carolina Medicaid Clinical Coverage Policy Physician: 1A-12 (Breast Surgeries) for the medical necessity clinical coverage criteria for breast reduction. Benefit coverage may be governed by federal, state, or contractual requirements, which take precedence where they differ from this policy.

Definition: North Carolina Medicaid Clinical Coverage Policy Physician: 1A-12 — the referenced source that contains the medical necessity clinical coverage criteria for breast surgeries, including breast reduction, which this UnitedHealthcare policy directs users to follow for North Carolina members.

Revision History

06/01/2025revised

06/01/2025 - Routine review; no change to coverage guidelines; archived previous policy version CSNC.MP.004.05. (Administrative update; coverage criteria unchanged.)

11/01/2025revisedLatest

11/01/2025 - Updated reference link to reflect the current policy title for Panniculectomy Surgery (for North Carolina Only). (Reference/related policies link updated.)