CurrentUnitedHealthcarePolicy CS011ID.A

Breast Reconstruction (for Idaho Only)

Policy governing coverage and medical necessity criteria for breast reconstruction procedures and related services for members in the state of Idaho, including Idaho Medicaid Plus plans.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reconstruction (for Idaho Only)

Policy CodePolicy CS011ID.A

Change TypeNo material change

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization per state-specific plan and contractual requirements when requesting reconstructive breast procedures for Idaho members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Idaho-onlystate-specific application

Allergan BIOCELLimplant removal covered

InterQual referencedexternal clinical criteria

CPT/HCPCS/ICD-10 listcoding appendix

Enumeratedcosmetic exclusions

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Medically Necessary Indications

Covered when reconstructive indication is documented (examples and references below):

Primary covered indications: Reconstruction during or after mastectomy or lumpectomy for treatment of breast cancer (immediate or delayed); treatment of congenital disorders causing breast deformity (e.g., Poland syndrome, Turner syndrome); correction of severe breast disfigurement from radiation or trauma (e.g., amastia); and reconstruction performed in conjunction with clinically indicated implant removal (see implant removal criteria).

Refer to InterQual CP: Procedures, Breast Reconstruction for specific clinical criteria.

Adjunct Reconstructive Procedures

Procedures considered reconstructive and medically necessary when performed with breast reconstruction:

Adjunct procedures: Creation of a nipple and areola (including tattooing); mastopexy or breast reduction when required prior to mastectomy to preserve nipple viability; reconstruction with a breast implant, including implantation of a tissue expander as the initial phase of reconstruction; and use of an acellular dermal matrix (ADM) (examples: AlloDerm™, Cortiva®, AlloMax™, DermACELL, FlexHD).

Specific ADM examples listed in policy.

Breast Implant Removal

Implant removal considered medically necessary when:

Implant removal indications: Removal of breast implants is considered reconstructive and medically necessary for 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); implant removal may be performed with or without capsulectomy/capsulotomy in certain circumstances per InterQual CP: Procedures, Breast Implant Removal.

See InterQual CP: Procedures, Breast Implant Removal for clinical detail.

Post‑Mastectomy Complications

Treatment for complications post-mastectomy that are covered:

Post-mastectomy complication treatments: Lymphedema management including complex decongestive physiotherapy (CDP); lymphedema pumps (considered durable medical equipment); and compression lymphedema sleeves (considered a prosthetic device).

Medically necessary reconstruction indications

Covered when reconstruction is performed for medically appropriate indications such as:

Indications for coverage: Reconstruction after lumpectomy or mastectomy for breast cancer; reconstruction for congenital anomalies (e.g., Poland syndrome) or disorders causing breast disfigurement; reconstruction for disfigurement from radiation or trauma; and reconstruction associated with removal of breast implants when clinically indicated (with or without capsulectomy/capsulotomy).

Based on Description of Services.

Cosmetic exclusions

Not covered (cosmetic) when ANY of the following apply:

Cosmetic exclusions: Procedures that correct an anatomical congenital anomaly without improving or restoring physiologic function; removal of aberrant breast tissue; aspirations; open or core biopsy; excision of duct lesions or cysts; excision of fibroadenomas or other benign (or nonreconstructive) tumors; removal of nipple or areolar lesions; treatment of gynecomastia; revision of a prior reconstructed breast due to normal aging; correction of tissue protruding at the end of a scar ('dog ear') unless it meets the reconstructive definition; breast enhancement (e.g., implants, mastopexy), liposuction; and breast surgery performed solely to create symmetry when not related to mastectomy.

Enumerated cosmetic exclusions; breast reconstruction for asymmetry for indications other than reconstructive reasons is cosmetic and not medically necessary.

Breast reconstruction performed solely to correct asymmetry is considered cosmetic and not medically necessary unless it is part of a documented reconstructive indication (for example, reconstruction during or after mastectomy). When asymmetry correction is integral to a covered reconstructive procedure (such as contralateral mastopexy performed to achieve symmetry following mastectomy reconstruction), it may be considered reconstructive and medically necessary. Providers should reference the InterQual criteria when documenting reconstructive intent and include clinical justification that the procedure is part of restoration after disease, trauma, or other covered indications.

Procedures that correct an anatomical congenital anomaly are considered reconstructive only when they improve or restore physiologic function. Corrections of congenital differences that do not restore function are treated as cosmetic and excluded from coverage. Examples of congenital indications that could support reconstructive coverage include conditions that produce functional impairment or major disfigurement (e.g., Poland syndrome) rather than isolated appearance concerns.

The policy explicitly excludes procedures that are diagnostic or minor therapeutic interventions from reconstruction coverage when not related to mastectomy. Excluded items include aspirations, open or core biopsies, excision of duct lesions, and excision of cysts. Removal of fibroadenomas or other benign (or non‑reconstructive) lesions and nipple/areolar lesion excision are also considered cosmetic exclusions unless they meet the definition of a reconstructive procedure tied to a covered indication.

Breast surgery performed exclusively to correct asymmetry is considered not medically necessary when it is not associated with a reconstructive indication such as treatment following mastectomy or significant trauma. If asymmetry correction is required as part of a covered reconstructive plan (for example, to preserve nipple viability or to achieve symmetry after cancer reconstruction), it may be covered; otherwise requests for asymmetry-only procedures should be considered cosmetic and may be denied.

Specific procedures listed as cosmetic exclusions when not related to mastectomy include: aberrant breast tissue removal, aspirations, biopsy (open or core), excision of duct lesions, excision of cysts, removal of fibroadenomas or other benign or malignant tumors (when not reconstructive), nipple or areolar lesion excision, treatment of gynecomastia, revision due to normal aging, correction of 'dog ear' scar tissue. Also excluded are routine cosmetic procedures such as breast enhancement (including implants and mastopexy), liposuction, and breast surgery performed solely to create symmetric breasts when they are not part of a reconstructive indication.

Any of the procedures listed above are considered not medically necessary and excluded from coverage when they are not performed in the context of a mastectomy or a nipple‑sparing reconstruction that meets reconstructive criteria. Providers should document the reconstructive indication clearly; absent that, these services will be treated as cosmetic and subject to denial.

Procedure and Diagnosis Codes

Applicable CPT Codes (partial list)CPT

11920

Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less

Applicable CPT Codes (continued)CPT

11921	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm.
11922	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure).
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 wound surface area.
15272	Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure).
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 harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure).
15777	Implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement (i.e.,

Covered/Reconstructive CPT CodesCPTCovered

19316	Mastopexy.
19325	Breast augmentation with implant.
19328	Removal of intact breast implant.
19330	Removal of ruptured breast implant, including implant contents (e.g., saline, silicone gel).
19340	Insertion of breast implant on same day of mastectomy (i.e., immediate).
19342	Insertion or replacement of breast implant on separate day from mastectomy.
19350	Nipple/areola reconstruction.
19355	Correction of inverted nipples.
19357	Tissue expander placement in breast reconstruction, including subsequent expansion(s).
19361	Breast reconstruction; with latissimus dorsi flap.

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HCPCS/Special Procedure CodesHCPCSCovered

L8600	Implantable breast prosthesis, silicone or equal
S2066	Breast reconstruction with gluteal artery perforator (GAP) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral
S2067	Breast reconstruction of a single breast with stacked deep inferior epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator (GAP) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateral.
S2068	Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral.
S8950	Complex lymphedema therapy, each 15 minutes

Applicable ICD-10 CodesICD-10

C50.011	Malignant neoplasm of nipple and areola, right female breast.
C50.012	Malignant neoplasm of nipple and areola, left 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.
I97.2	Postmastectomy lymphedema syndrome.
N65.0	Deformity of reconstructed breast.
T85.43XA	Leakage of breast prosthesis and implant, initial encounter.
Z42.1	Encounter for breast reconstruction following mastectomy.
Z45.811	Encounter for adjustment or removal of right breast implant.

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Identification window for congenital anomaly

Identification windowCongenital anomaly must be identified within the first 12 months of birth.

Definition contextA congenital anomaly is a physical developmental defect present at the time of birth.

Reference sourceCOC, 2018 as cited in policy definitions.

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

State-specific Prior Authorization Required

Prior authorization is required for breast reconstruction services in Idaho. This Medical Policy applies only to the state of Idaho (including Idaho Medicaid Plus plans); obtain prior authorization according to the member's benefit plan and any applicable state-specific rules before scheduling services.

State: Idaho (including Idaho Medicaid Plus)
Prior authorization required per plan and state rules

Prior Authorization

Prior Authorization and Benefit Considerations

Coverage is subject to the member's federal, state or contractual benefit plan, applicable laws, and network availability. A gap exception may be granted if no in-network provider is available to provide the requested reconstructive procedure. Prior authorization does not guarantee payment; benefits, limits, exclusions, and applicable contractual rules must be confirmed.

Gap exception may be granted when no in‑network provider is available
Verify member benefits, limitations, exclusions, and network requirements prior to service

Denial Risk

Cosmetic Exclusions May Trigger Denial

Procedures that correct an anatomical congenital anomaly without improving or restoring physiologic function are considered cosmetic and excluded from coverage. Examples of cosmetic exclusions that may trigger denial are provided below.

Cosmetic exclusions (not covered) when not related to mastectomy: Breast enhancement (e.g., breast implants, mastopexy); Liposuction; Breast surgery for the purpose of creating symmetrical breasts
Cosmetic indications considered excluded: 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') — note: painful scars or donor site scar revisions must meet the definition of a reconstructive procedure to be considered for coverage.

Documentation Required

Documentation and Regulatory Context

Medical records documentation may be required to determine whether the member meets clinical criteria for coverage. Reviewers will refer to Medical Policy documentation and applicable federal, state, or contractual requirements. Documentation should clearly state the reconstructive indication, prior surgeries, symptoms, functional impairment, and any relevant pathology or congenital diagnosis.

Include clinical history, operative reports, pathology, imaging, and records of prior treatments (e.g., radiation, chemotherapy)
Document physiologic benefit or functional impairment when the reconstruction is for congenital anomalies or scar/donor-site issues

Billing Rule

Intraoperative Assessment Billing Note

Intraoperative assessment of vascular perfusion is considered an integral part of breast reconstruction and is not separately reimbursable; do not bill separately for perfusion assessment when submitted with reconstruction.

Do not submit separate claims or codes for intraoperative perfusion assessment when billed with reconstructive breast surgery

Key Terms and Definitions

Acellular Dermal Matrix (ADM)

DefinitionAcellular Dermal Matrix (ADM) is 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).

Common useUsed for soft tissue reinforcement in breast reconstruction, e.g., implant support and coverage.

Regulatory noteFDA referenced in definition (2021).

Mastectomy

DefinitionMastectomy: surgery to remove all or part of the breast.

VarietiesDifferent types of mastectomy differ by the amount of breast tissue and lymph nodes removed.

Clinical contextMay be performed for cancer treatment and can prompt immediate or delayed reconstruction.

Congenital Anomaly

DefinitionCongenital Anomaly: a physical developmental defect present at the time of birth and identified within the first twelve months of birth.

Coverage relevanceReconstruction for congenital anomalies is a listed medically necessary indication when identified within the 12-month window.

Policy sourceCOC, 2018 as cited in definitions.

Anaplastic Lymphoma (including BIA-ALCL presentation)

DefinitionAnaplastic Lymphoma: a rare type of non-Hodgkin lymphoma, one of the T‑cell lymphoma subtypes.

Typical presentation (BIA-ALCL)Breast implant-associated ALCL most commonly presents as a delayed fluid collection (seroma) around a textured implant or as a mass in the fibrous capsule surrounding the implant.

Epidemiology noteRepresents about 1% of all NHLs and ~16% of T‑cell lymphomas (Lymphoma Research Foundation cited).

Reconstructive breast surgery

DefinitionReconstructive breast surgery: surgical procedures to restore the normal appearance of the breasts after cancer surgery, congenital anomaly, trauma, radiation injury, or implant removal.

TimingReconstruction can be immediate (at time of surgery) or delayed until after adjuvant therapy or patient decision.

Included proceduresMay include contralateral mastopexy and a variety of techniques (implant-based or autologous flaps).

BIA-ALCL

DefinitionBreast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a recently recognized T‑cell non‑Hodgkin lymphoma that can develop around breast implants, most commonly textured-surface implants.

Associated implant typesHas been reported with both silicone and saline implants; most commonly associated with textured surfaces.

Clinical course notePresentation frequently includes delayed seroma or a mass within the fibrous capsule surrounding the implant; pathogenesis remains unclear.

OpenPayer

Breast Reconstruction (for Idaho Only)

Coverage and Medical Necessity Criteria

Procedure and Diagnosis Codes

Prior Authorization, Documentation, and Billing Guidance

Clinical Background and Rationale

Key Terms and Definitions

Policy Revision History