UnitedHealthcare breast reconstruction Coverage Update

Coverage and Medical Necessity Criteria

Medically Necessary Reconstruction

Covered when ALL of the following are met:

Reconstruction indication: Breast reconstruction during or post mastectomy and for treatment of congenital disorder (e.g., Poland syndrome; Turner syndrome) or severe breast disfigurement (e.g., amastia, radiation) is considered reconstructive and medically necessary in certain circumstances.

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

Associated procedures considered reconstructive: Mastopexy or breast reduction when required to preserve nipple viability prior to mastectomy; creation of a nipple and areola (including tattooing); reconstruction with a breast implant with or without acellular dermal matrix (ADM); implantation of a tissue expander as the initial phase of reconstruction.

These procedures may be considered reconstructive when performed with a breast reconstructive procedure.

Complication treatments covered: Treatment for complications post mastectomy such as complex decongestive physiotherapy, lymphedema pumps, compression sleeves, elastic bandages/wraps for lymphedema, and postoperative infections are covered and medically necessary.

Lymphedema supplies may be billed as durable medical equipment or prosthetic devices per benefit terms.

Implant removal: Removal of breast implants, with or without capsulectomy/capsulotomy, is considered reconstructive and medically necessary in certain circumstances, including for individuals implanted with Allergan BIOCELL textured breast implants regardless of reason for initial placement.

For clinical criteria, refer to InterQual CP: Procedures, Breast Implant Removal.

Cosmetic/Excluded Procedures

Not covered when ALL of the following apply:

Cosmetic indications: Procedures that correct an anatomical congenital anomaly without improving or restoring physiologic function are considered cosmetic. Breast reconstruction for asymmetry for indications other than post-mastectomy, congenital anomaly, or severe disfigurement is considered cosmetic and not medically necessary.

Refer to Benefit Considerations for the full list of cosmetic exclusions.

Cosmetic / Not Covered

Coverage statements and exclusions noted in this section apply:

Cosmetic Exclusions: Procedures that correct an anatomical congenital anomaly without improving or restoring physiologic function are considered cosmetic and excluded. Specific excluded procedures include aberrant breast tissue treatments, aspirations, duct lesion procedures, biopsies, cyst excision, nipple/areolar lesion procedures, fibroadenomas, treatment of gynecomastia, dog-ear revisions, and revision of a reconstructed breast for normal aging. Additionally, liposuction, breast enhancement (implants, mastopexy), and breast surgery solely to create symmetry are excluded when not related to mastectomy.

Policy history clarifies language about asymmetry and cosmetic exclusions.

Implant Removal – Allergan BIOCELL

Covered when ALL of the following are met:

Implant removal for Allergan BIOCELL textured implants: 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).

Policy History added this specific coverage statement; refer to clinical evidence and InterQual for additional guidance.

This policy excludes procedures that are performed for purely cosmetic purposes and procedures intended solely to create breast symmetry when not related to a mastectomy. Specifically, procedures that correct an anatomical congenital anomaly without improving or restoring physiologic function are considered cosmetic and excluded from coverage. See the list below for examples of procedures that are excluded when not performed as part of reconstructive care following mastectomy or other covered indications.

Examples of procedures considered cosmetic and excluded from coverage when not related to mastectomy include: liposuction; breast enhancement procedures such as breast implants and mastopexy; excision of aberrant breast tissue, aspirations and duct lesion procedures performed for cosmetic reasons; removal of cysts; procedures for nipple or areolar lesions performed for cosmetic indications; treatment of gynecomastia when cosmetic in intent; and breast surgery performed solely for the purpose of creating symmetrical breasts.

Breast reconstruction performed solely to correct asymmetry is considered cosmetic and not medically necessary when the indication is other than post-mastectomy, a congenital anomaly, or severe breast disfigurement. When asymmetry is not the result of those reconstructive indications, coverage for procedures addressing asymmetry is excluded.

Restating the policy position: breast reconstruction for asymmetry for indications not listed in the policy as reconstructive and medically necessary is considered cosmetic and not medically necessary. This clarification reflects the revised coverage rationale in the policy history and should be applied when determining eligibility for coverage of symmetry procedures.

Codes and Reimbursement Notes

Covered CPT Codes (selected excerpt)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, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6. 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.
11970	Replacement of tissue expander with permanent implant.
11971	Removal of tissue expander without insertion of implant.

Covered CPT Codes (continued)CPTCovered

15271	Application of skin substitute to trunk, arms, legs; total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area graft.
15272	Application of skin substitute to trunk, arms; legs; total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area.
15771	Grafting of autologous fat harvested by liposuction technique to trunk; breasts, scalp, arms, and/or legs; 50 cc or less injectate.
15772	Each additional 50 cc injectate (list separately in addition to code for primary procedure).
15777	Implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement.
19316	Mastopexy.
19325	Breast augmentation with implant.
19328	Removal of intact breast implant.
19330	Removal of ruptured breast implant; including implant contents.
19340	Insertion of breast implant on same day as mastectomy (immediate).

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Covered CPT/HCPCS Codes (flap and revision codes)mixedCovered

19361	Breast reconstruction; with latissimus dorsi flap.
19364	Breast reconstruction; with free flap.
19367	Breast reconstruction; with single-pedicled TRAM flap.
19368	Breast reconstruction; with single-pedicled TRAM requiring separate microvascular anastomosis (supercharging).
19369	Breast reconstruction; with bipedicled TRAM flap.
19370	Revision of peri-implant capsule, breast; including capsulotomy, capsulorrhaphy, and/or partial capsulectomy.
19371	Peri-implant capsulectomy, breast; complete, including removal of all intracapsular contents.
19380	Revision of reconstructed breast.
19396	Preparation of moulage for custom breast implant.
19499	Unlisted procedure, breast.

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Relevant ICD-10 Diagnosis Codes (selected)ICD-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.
197.2	Postmastectomy lymphedema syndrome.
N65.0	Deformity of reconstructed breast.
N65.1	Disproportion of reconstructed breast.
Q79.8	Other congenital malformations of musculoskeletal system.
T85.43XA	Leakage of breast prosthesis and implant; initial encounter.

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Applicable Codes (referenced)mixed

affected codes

Policy references changes to Applicable Codes; specific codes listed in other policy part(s).

Reimbursement notesmixed

intraoperative perfusion assessment

Not separately reimbursable; considered integral to breast reconstruction.

Skin substitute graft area — reporting thresholds

Initial graft areaFirst 25 square centimeters or less (code 15271).

Additional unitsEach additional 25 square centimeters reported separately (code 15272).

Applicable procedure contextSkin substitute codes apply to trunk, arms, and legs wound surface area up to 100 sq cm as described in coding list.

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization required. Prior authorization requirements apply per the member's plan. A gap exception may be granted if there is not an in-network provider able to provide the requested reconstructive procedure. Check the member's federal, state, and contractual benefit requirements for specific prior authorization processes and timelines.

Prior authorization applies per plan; verify member benefits and obtain authorization when required.
Gap exception: may be granted if no in-network provider can provide the requested reconstructive procedure.
Reference InterQual criteria for medical necessity determinations for breast reconstruction.

Denial Risk

Cosmetic Procedures — Excluded

Cosmetic exclusions. Procedures that correct an anatomical congenital anomaly without improving or restoring physiologic function are considered cosmetic and excluded. Breast reconstruction for asymmetry for indications not listed as reconstructive/medically necessary is considered cosmetic and not medically necessary. Additional cosmetic exclusions apply when not related to mastectomy.

Clinical Background and Rationale

Breast reconstruction aims to restore breast form and appearance after mastectomy or other causes of breast disfigurement and may be performed either immediately at the time of mastectomy or delayed after initial treatment depending on oncologic therapy and patient preference. Indications for reconstructive procedures include restoration following mastectomy for cancer, reconstruction for congenital anomalies (for example, Poland syndrome), and correction of severe deformity from radiation or trauma. Associated procedures—such as tissue expander placement, implant reconstruction (with or without acellular dermal matrix), nipple and areola creation (including tattooing), and mastopexy or reduction when required as part of reconstruction to preserve nipple viability—may be part of a reconstructive plan. Management of post-mastectomy complications (for example, lymphedema therapy or treatment of infection) is also considered part of medically necessary reconstructive care.

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 (matrix) is left in place.

Typical useUsed as a biologic implant for soft tissue reinforcement in breast and trunk reconstruction (e.g., implantation of biologic implant, code 15777).

Regulatory noteFDA informational context referenced; federal/state/contractual definitions supersede these definitions when applicable.

Anaplastic Lymphoma (general and BIA context)

DefinitionAnaplastic Lymphoma is a rare type of non-Hodgkin lymphoma, a subtype of T-cell lymphoma, comprising about 1% of all NHLs and ~16% of T-cell lymphomas.

Breast-implant presentation

OpenPayer

Breast Reconstruction (for Kentucky Only)

Coverage and Medical Necessity Criteria

Codes and Reimbursement Notes

Provider Requirements, Prior Authorization, and Documentation

Clinical Background and Rationale

Definitions