CurrentUnitedHealthcarePolicy CS011IN.10

Breast Reconstruction (for Indiana Only)

Defines UnitedHealthcare Community Plan of Indiana coverage positions for reconstructive breast surgery and related procedures, including indications post-mastectomy, congenital anomalies, implant removal for Allergan BIOCELL textured implants, related adjunct procedures (nipple/areola creation, ADM use, tissue expanders), lymphedema treatments, and exclusions for cosmetic indications.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reconstruction (for Indiana Only)

Policy CodePolicy CS011IN.10

Change TypeDocumentation updatescode removalsupporting info revised

Effective DateFeb 1, 2026

Next Review Date

Key ActionPatient medical record must contain documentation supporting medical necessity including relevant medical history, physical exam, and pertinent diagnostic test results; documentation must be legible and available upon request.

SourceLink

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

POLICY UPDATE CHANGES

Added language clarifying medical records documentation requirements for reviews (including that documentation may be required, must fully support medical necessity, and be made available upon request).

Removed CPT code 19380 from the Applicable Codes section.

Updated Supporting Information sections: Clinical Evidence, FDA, and References to reflect current information.

Indiana-onlyGeographic scope

InterQualClinical criteria source

Allergan BIOCELLImplant removal mandated

ADM, expanders, nipple/areolaAdjuncts included

1Removed CPT codes

1Documentation requirement topics added

Coverage Summary

Scope: UnitedHealthcare Community Plan of Indiana medical policy CS011IN.10 (effective February 1, 2026) applies only to members in Indiana and references InterQual clinical criteria for detailed medical necessity determinations. The policy takes a mixed coverage stance: reconstructive breast procedures and certain related therapies are covered when criteria are met, while cosmetic indications are excluded.

Summary of coverage: The policy covers breast reconstruction during or after mastectomy and for treatment of congenital disorders or severe breast disfigurement, including associated adjunct procedures (e.g., nipple/areola creation/tattooing, mastopexy when required prior to mastectomy, implant-based reconstruction with tissue expanders) and use of Acellular Dermal Matrix (ADM) when part of reconstructive surgery. It also covers management of post-mastectomy complications such as lymphedema treatments (complex decongestive physiotherapy, lymphedema pumps, compression sleeves, elastic bandages) and implant removal for individuals with Allergan BIOCELL textured implants. The policy excludes procedures performed for purely cosmetic indications (e.g., breast enhancement, mastopexy not related to mastectomy, liposuction, correction of asymmetry not related to mastectomy/congenital disorder).

Policy metadata (compact)

Policy NumberCS011IN.10

Effective Date2026-02-01

Last Review2026-02-01

Geographic scopeIndiana-only

Clinical criteria sourceInterQual CP: Procedures, Breast Reconstruction / Breast Implant Removal

StatusCURRENT

Has material changetrue

Medical-Necessity Criteria

Medically necessary reconstructive breast surgery

Covered when ALL of the following are met:

ALL of the following

Procedure is breast reconstruction during or post mastectomy OR for treatment of a congenital disorder (e.g., Poland syndrome, Turner syndrome) or severe breast disfigurement (e.g., amastia, radiation)
Medical necessity clinical coverage criteria referenced: InterQual CP: Procedures, Breast Reconstruction

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:

ANY of the following

Coding

Referenced CPT codes (includes reconstructive, adjunct, and related procedures)CPT

11920	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, <=6.0 sq cm
11921	Tattooing, intradermal introduction of insoluble opaque pigments; 6.1 to 20.0 sq cm
11922	Tattooing, intradermal; 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, arms, legs; total wound surface area up to 100 sq cm; first 25 sq cm or less
15272	Application of skin substitute graft; each additional 25 sq cm
15771	Grafting of autologous fat by liposuction; 50 cc or less injectate
15772	Grafting of autologous fat; each additional 50 cc injectate
15777	Implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement

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Additional HCPCS / local codes (implant/prosthesis and flap procedures)HCPCS

L8600	Implantable breast prosthesis, silicone or equal
S2066	Breast reconstruction with gluteal artery perforator (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

Diagnosis codes referencedICD-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 not managed for medical necessity review in Indiana (asterisked)mixed

11920	See main CPT list (asterisk indicates not managed for medical necessity review in Indiana at effective date)
11970	Replacement of tissue expander with permanent implant (asterisked)
11971	Removal of tissue expander without insertion of implant (asterisked)
15271	Application of skin substitute graft (asterisked)
15272	Application of skin substitute graft additional (asterisked)
15771	Autologous fat grafting <=50 cc (asterisked)
15772	Autologous fat grafting additional 50 cc (asterisked)
15777	Implantation of biologic implant (ADM) (asterisked)
19328	Removal of intact breast implant (asterisked)
19330	Removal of ruptured breast implant (asterisked)

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Removed/Updated CPT CodesCPT

19380

Removed from applicable codes for this policy (no longer listed as applicable)

Provider Actions / Requirements

Documentation Required

Document medical necessity in medical record

The patient's medical record must contain documentation that fully supports medical necessity; include relevant history, physical exam findings, and results of pertinent diagnostic tests or procedures. Ensure records are legible and maintained so they can be produced if requested for review.

relevant medical history
physical examination
pertinent diagnostic test results
legible and available upon request

Prior Authorization

Prior authorization / InterQual criteria required

InterQual clinical coverage criteria (InterQual CP: Procedures, Breast Reconstruction and InterQual CP: Procedures, Breast Implant Removal) are referenced for medical necessity determinations. Providers should verify the payer's prior authorization and notification requirements for Indiana before scheduling or performing services.

Background & Evidence

Background: Reconstructive breast surgery may be required after lumpectomy or mastectomy for breast cancer or to restore anatomy after congenital conditions (e.g., Poland syndrome), radiation, trauma, or severe disfigurement; reconstruction can be immediate or delayed. The policy references InterQual clinical criteria (InterQual CP: Procedures, Breast Reconstruction and Breast Implant Removal) for medical necessity determinations and notes that federal, state, or contractual requirements may affect coverage.

Associated procedures and treatments: When performed with reconstructive breast surgery, covered adjuncts include creation of the nipple and areola (including tattooing), mastopexy or reduction when needed to preserve nipple viability prior to mastectomy, implant-based reconstruction with tissue expanders, and use of ADM. Post-mastectomy complications covered include lymphedema care (complex decongestive therapy, pumps, compression sleeves, bandages) and treatment of post-operative infections. Implant removal is considered reconstructive and medically necessary for individuals implanted with Allergan BIOCELL textured implants, with or without capsulectomy/capsulotomy as indicated.

Regulatory context: The policy cites FDA communications relevant to implants, tissue expanders, and ADM products — including the 2019 Allergan BIOCELL textured implant recall and FDA advisories about ADM products and breast implant safety — and clarifies that implants, expanders, and ADMs require FDA approval while reconstruction procedures themselves are surgical and not FDA-regulated as devices.

Documentation expectations: The policy adds required medical records documentation language specifying that the patient’s record must fully support medical necessity (relevant history, physical exam, and diagnostic test results), be legible, maintained in the record, and be made available upon request for reviews.

Key evidence items

Revision History

2026-02-01added (material)Latest

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

2026-02-01removed (material)Latest

Removed CPT code 19380 from the Applicable Codes section; guidance notes not to bill CPT 19380 under this policy as it was removed effective 2026-02-01 and to verify federal, state, or contractual requirements which may differ.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reconstruction (for Indiana Only)

Policy CodePolicy CS011IN.10

Change TypeDocumentation updatescode removalsupporting info revised

Effective DateFeb 1, 2026

Next Review Date

SourceLink

On This Page

Creation of a nipple (by various techniques) and areola (tattooing)

Mastopexy or breast reduction when required prior to mastectomy to preserve viability of the nipple

Reconstruction with a breast implant (with or without implantation of a tissue expander as initial phase)

Use of an Acellular Dermal Matrix (ADM), e.g., AlloDerm, Cortiva, AlloMax, DermACELL, FlexHD

ADM defined in policy definitions and FDA advisory referenced

Treatment of complications post-mastectomy (covered)

Covered and medically necessary for the following complications:

ANY of the following

Lymphedema, including complex decongestive physiotherapy (CDP)
Lymphedema pumps (considered durable medical equipment)
Compression lymphedema sleeves (considered a prosthetic device)
Elastic bandages and wraps associated with medically necessary treatments for lymphedema complications
Post-operative infection(s)

Removal of breast implants (covered)

Removal is considered reconstructive and medically necessary when ANY of the following are met:

ANY of the following

Individuals implanted with Allergan BIOCELL textured breast implants regardless of reason for initial placement due to increased risk of BIA-ALCL
Removal with or without capsulectomy/capsulotomy in certain circumstances (see InterQual CP: Procedures, Breast Implant Removal)
Referenced InterQual criteria for specifics

Nipple repair/reconstruction for inverted nipples (covered)

Covered when ONE of the following are met:

ANY of the following

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

Cosmetic / Not medically necessary

Not covered when ALL of the following apply (i.e., cosmetic):

Considered cosmetic and not medically necessary: Breast reconstruction for asymmetry for all other indications (not related to mastectomy/congenital disorder/severe disfigurement)

Examples of cosmetic/excluded indications (not related to mastectomy)

Aberrant breast tissue
Aspirations
Biopsy (open or core)
Duct lesions
Excision of cysts
Fibroadenomas or other benign or malignant tumors
Nipple or areolar lesions
Treatment of gynecomastia
Revision of a prior reconstructed breast due to normal aging
Tissue protruding at the end of a scar ('dog ear'/standing cone)
Painful scars or donor site scar revisions must meet reconstructive definition to be considered for coverage
Breast enhancement (e.g., breast implants, mastopexy) when not related to mastectomy
Liposuction when not related to mastectomy
Breast surgery for the purpose of creating symmetrical breasts (when not related to mastectomy)

Medical Records Documentation Used for Reviews

Added language specifying documentation expectations:

Benefit coverage for health services is determined by the federal, state, or contractual requirements, and applicable laws that may require coverage for a specific service

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services

This documentation includes but is not limited to relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures

Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available upon request

Indiana prior authorization and notification list
InterQual CP: Procedures, Breast Reconstruction and InterQual CP: Procedures, Breast Implant Removal

Prior Authorization

Some CPT/HCPCS codes not managed for medical necessity review

Codes marked with an asterisk in the policy are not managed for medical necessity review for the state of Indiana as of the policy effective date; providers must consult the current payer prior authorization list to confirm which codes require review.

Consult the payer prior authorization list for Indiana to confirm current managed code lists

Billing Rule

Intraoperative perfusion assessment not separately reimbursable

Intraoperative assessment of vascular perfusion is considered an integral part of breast reconstruction and is not separately reimbursable under this policy.

Billing Rule

Code removal impact

CPT code 19380 has been removed from the applicable codes list and should not be billed under this policy effective February 1, 2026; verify any federal, state, or contractual requirements which may differ or govern reimbursement.

19380 (removed effective 2026-02-01) - verify governing/federal/state/contractual authorities

Documentation Required

State-specific applicability

This policy applies only to members in the state of Indiana; providers must refer to applicable federal, state, or contractual requirements for coverage rules that may supersede this policy.

Documentation Required

Maintain medical record documentation supporting medical necessity

Maintain legible medical record documentation that fully supports the medical necessity for requested services; documentation may be requested for review but its presence does not guarantee coverage.

Documentation must be legible and maintained in the patient's medical record
Records should fully support medical necessity and be made available upon request

Documentation Required

Reference governing authorities for coverage decisions

When determining coverage and payment, consult federal, state, and contractual requirements because they may override the standard benefit policy.

ADM comparative outcomes (Ng et al. 2024)No significant differences in postoperative complications between ADM and non-ADM groups in included studies

BREASTrial (Mendenhall et al. 2023)No difference in overall complication rates between AlloDerm and DermaMatrix

BIA-ALCL evidence (Clemens et al. 2024)Systematic review highlights association of BIA-ALCL with textured implants and need for surveillance

Cordeiro cohort (2020)Reported BIA-ALCL risk 0.311 cases per 1000 person-years in cohort with macro-textured implants

Definitions: Acellular Dermal Matrix (ADM) — a type of surgical mesh developed from human or animal skin in which the cells are removed leaving the support structure (FDA 2021).

Anaplastic Lymphoma — a rare T‑cell non‑Hodgkin lymphoma; breast implant–associated ALCL 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 present at birth and identified within the first twelve months of life.

Mastectomy — surgery to remove all or part of the breast; types vary by amount of tissue and lymph nodes removed.

Mastopexy/Breast Lift — a procedure that raises the breast, removes excess skin, and tightens surrounding tissue.

2026-02-01revised (non-material)Latest

Updated Supporting Information sections: Clinical Evidence, FDA, and References to reflect the most current information; previous policy version CS011IN.09 archived.