UnitedHealthcare Breast Reconstruction Coverage Update

Medically Necessary and Not Medically Necessary Indications

Medically Necessary — Reconstructive Breast Surgery

Breast reconstruction is considered reconstructive and medically necessary in the following circumstances:

ANY of the following indications

Breast reconstruction after mastectomy (with or without a cancer diagnosis)
For medical necessity clinical coverage criteria, refer to InterQual CP: Procedures, Breast Reconstruction.
Reconstruction for congenital disorders causing absent or malformed breast (e.g., Poland syndrome, Turner syndrome)
Reconstruction for severe breast disfigurement (e.g., amastia, radiation-related disfigurement)

Medically Necessary — Procedures Considered Reconstructive When Performed with Breast Reconstruction

The following procedures may be considered reconstructive and medically necessary when performed with a breast reconstructive procedure:

ALL of the following

Creation of nipple (various techniques) and areola tattooing
Reconstruction with a breast implant (including implant-based reconstruction) — may include adjunct procedures
Mastopexy or breast reduction when required prior to mastectomy to preserve nipple viability
Implantation of a tissue expander as the initial phase of reconstruction
Use of an Acellular Dermal Matrix (ADM) such as AlloDerm, Cortiva, AlloMax, DermACELL, FlexHD

Medically Necessary — Treatment of Post-Mastectomy Complications

Treatment for complications post mastectomy is covered and medically necessary for the following:

ALL of the following

Complex decongestive physiotherapy (CDP)
Lymphedema treatments including lymphedema pumps (considered durable medical equipment)
Elastic bandages and wraps for medically necessary lymphedema treatment
Compression lymphedema sleeves (considered a prosthetic device)
Treatment of post-operative infections

Medically Necessary — Removal of Breast Implants

Removal of breast implants is considered reconstructive and medically necessary in the following circumstances:

ANY of the following

Implant removal with or without capsulectomy/capsulotomy in certain circumstances — see InterQual CP: Procedures, Breast Implant Removal for medical necessity criteria
InterQual referenced for specific clinical criteria.
Individuals implanted with Allergan BIOCELL textured breast implants regardless of reason for initial placement due to increased risk of breast implant–associated anaplastic large cell lymphoma (BIA-ALCL)

Medically Necessary — Inverted Nipple Correction (Non–post-mastectomy)

Breast repair and reconstruction procedures not post-mastectomy are considered reconstructive and medically necessary for correction of inverted nipples when ONE of the following is met:

ANY of the following

Correction of an inverted nipple(s) resulting from a congenital anomaly
Documented history of chronic nipple discharge, bleeding, scabbing, or ductal infection

Not Medically Necessary / Cosmetic

Breast reconstruction for asymmetry for indications other than those above is considered cosmetic and not medically necessary.

ALL of the following

Procedures performed solely for breast asymmetry not associated with mastectomy, congenital anomaly, severe disfigurement, or other listed reconstructive indications

Relevant CPT, HCPCS and ICD-10 Codes (for reference)

Covered / Reconstructive CPT Codes (listed for reference)CPTCovered

11920	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 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 first 25 sq cm or less wound surface area graft
15272	Application of skin substitute graft to trunk, arms, legs, etc.; up to 100 sq cm; each additional 25 sq cm
15771	Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate
15772	Grafting of autologous fat; each additional 50 cc injectate
15777	Unspecified in text (listed)

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Covered / HCPCS and Proprietary Codes (listed for reference)HCPCS/mixedCovered

L8600	Implantable breast prosthesis, silicone or equal
S2066	Breast reconstruction with gluteal artery perforator (GAP) including harvesting and microvascular transfer; unilateral
S2067	Breast reconstruction with 'stacked' DIEP and/or GAP flap(s); unilateral
S2068	Breast reconstruction with DIEP or SIEA flap; unilateral
S8950	Complex lymphedema therapy, each 15 minutes

Reference / Diagnosis Codes (ICD-10) — relevant conditions and encountersICD-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
C79.81	Secondary malignant neoplasm of breast
C84.7A	Anaplastic large cell lymphoma, ALK-negative, breast
D05.00	Lobular carcinoma in situ of unspecified breast
D05.11	Intraductal carcinoma in situ of right breast
D48.61	Neoplasm of uncertain behavior of right breast
197.2	Postmastectomy lymphedema syndrome (note: legacy/other code system present)
N65.0	Deformity of reconstructed breast

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Prior Authorization, Documentation, and Denial Risks

Prior Authorization

Prior authorization / clinical criteria referenced

Obtain prior authorization when required by the member's plan and provide clinical documentation aligned with the InterQual CP: Procedures (Breast Reconstruction; Breast Implant Removal) when a prior authorization or coverage determination is requested.

Documentation Required

Use InterQual criteria for medical necessity determinations

UnitedHealthcare references InterQual CP: Procedures for medical necessity determinations; when requesting prior authorization or a coverage determination, document the specific clinical information required by the InterQual Breast Reconstruction and Breast Implant Removal criteria.

Documentation Required

Implant removal for Allergan BIOCELL textured implants

Clinical and Policy Background

This policy addresses reconstructive breast procedures performed after mastectomy (either immediate or delayed), as well as reconstruction for congenital absence or deformity (for example, Poland syndrome or Turner syndrome), and for severe disfigurement related to radiation or trauma. It also covers surgical management of post‑mastectomy complications, including lymphedema and postoperative infections. For detailed medical necessity criteria the policy references InterQual CP: Procedures, Breast Reconstruction and directs reviewers to use InterQual when prior authorization or a coverage determination is requested.

Procedures commonly considered reconstructive when performed with breast reconstruction include creation of the nipple and areola (including tattooing), implant‑based reconstruction (which may involve tissue expanders and later placement of permanent implants), mastopexy or reduction when needed to preserve nipple viability, and use of an Acellular Dermal Matrix (ADM) product (examples cited include AlloDerm, Cortiva, AlloMax, DermACELL, and FlexHD). The policy notes ADM is a surgical mesh from which cells have been removed, leaving the structural matrix, and that ADM products used in implant reconstruction are medical devices addressed in FDA communications.

Treatment of post‑mastectomy complications is covered when medically necessary and includes complex decongestive physiotherapy (CDP), conservative lymphedema measures (compression garments, lymphedema pumps and elastic bandages/wraps), and care for postoperative infections. The policy cites evidence and randomized trials supporting bandaging and early compression for prevention and management of breast cancer–related lymphedema.

Removal of breast implants is considered reconstructive and medically necessary in specified circumstances; providers should refer to InterQual CP: Procedures, Breast Implant Removal for clinical criteria. The policy also specifies that removal of Allergan BIOCELL textured implants is considered reconstructive and medically necessary regardless of the reason for the initial implant placement because of the elevated risk of breast implant–associated anaplastic large cell lymphoma (BIA‑ALCL). The document summarizes the BIA‑ALCL literature, including its association with textured implants, typical clinical presentation, and guidance that implant and capsule removal (complete capsulectomy) is preferred for disease confined to the capsule or seroma.

Key Terms

Definitions

Acellular Dermal Matrix (ADM)A type of surgical mesh developed from human or animal skin, in which the cells are removed, leaving the structural matrix.

Anaplastic large cell lymphoma (ALCL)A rare T‑cell non‑Hodgkin lymphoma; when associated with breast implants it most commonly presents as delayed fluid collection around textured implants or as a mass in the fibrous capsule (BIA‑ALCL).

MastectomySurgery to remove all or part of the breast; different types vary by amount of tissue and lymph nodes removed.

MastopexyA breast lift procedure that raises the breast, removes excess skin, and tightens surrounding tissue.

Women's Health and Cancer Rights Act of 1998 (WHCRA)Federal law requiring group health plans that cover mastectomy to also provide coverage for breast reconstruction (including reconstruction of the contralateral breast for symmetry), prostheses, and treatment of physical complications including lymphedema, as determined in consultation with the attending physician and patient.

Policy Update Changes

10/01/2025Policy history updateLatest

Supporting information updated: Clinical Evidence and References sections revised; Policy History notes updated to indicate the prior version UMRMP.003.25 was archived. Marked as non‑material (no explicit clinical coverage rule changes documented).