RetiredUnitedHealthcarePolicy CS011LA.Q

Breast Reconstruction (for Louisiana Only)

State-specific Louisiana Medicaid policy governing coverage and coding for reconstructive breast surgery after therapeutic intervention or trauma; applies to providers and members in Louisiana while the policy was active. The document was retired effective April 1, 2026 and previously effective November 1, 2025–March 31, 2026.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reconstruction (for Louisiana Only)

Policy CodePolicy CS011LA.Q

Change TypeRetirementdocumentation language added

Effective DateNov 1, 2025

Next Review Date

Key ActionEnsure patient medical records include history, physical exam, and pertinent diagnostic results to support medical necessity and make documentation available upon request.

SourceLink

POLICY UPDATE CHANGES

Policy retired; Louisiana plan membership disenrolled on Apr. 1, 2026.

Medical records documentation language requiring documentation that fully supports medical necessity was added.

1 statepolicy applies to (Louisiana only)

~40+procedure codes listed

numerousdiagnosis codes listed

Retired 04/01/2026policy retirement date

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Coverage and Medical Necessity Criteria

Medically Necessary Reconstruction

Covered when ALL of the following are met

Reconstructive Indication: Surgery is performed after a therapeutic intervention (e.g., mastectomy) or trauma resulting in significant loss of breast tissue.

Covered Services: Reconstruction of the affected breast; reconstruction of the contralateral breast for symmetry; prostheses (implanted, external, or both); treatment of complications of the reconstruction.

All prosthetic implants must be FDA approved and used in compliance with all FDA requirements at the time of the surgery.

Related Procedures: Reduction mammoplasty and removal of breast implants for the purpose of breast reconstruction are covered under this policy.

Codes marked with an asterisk in the procedure and supply lists are not present on the State of Louisiana Medicaid Fee Schedule and therefore are not covered by the State of Louisiana Medicaid Program. These codes are included for reference only and should not be interpreted as payable under Louisiana Medicaid.

Listing a procedure or diagnosis code in this policy is for reference purposes only and does not by itself indicate that the service is covered. Benefit coverage is governed by federal, state, or contractual requirements and applicable laws, and inclusion of a code does not guarantee reimbursement or claim payment. Providers should verify coverage under the applicable benefit plan and state rules before billing.

Procedure and Diagnosis Codes

Covered/Listed CPT codesCPTCovered

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; 6.1 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(s) 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)h.
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., breast, trunk) (List separately in addition to code for primary procedure).

1–10 of 29

1/3

Codes not on Louisiana Medicaid fee schedule (not covered by State program)mixedNot Covered

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.

Diagnosis (ICD-10) codes listedICD-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.
D05.11	Intraductal carcinoma in situ of right breast.
D48.61	Neoplasm of uncertain behavior of right breast.
N65.0	Deformity of reconstructed breast / Disproportion of reconstructed breast.
T85.43XA	Leakage of breast prosthesis and implant, initial encounter.
Z42.1	Encounter for breast reconstruction following mastectomy.
Z90.11	Acquired absence of right breast and nipple.

Skin substitute graft area — area-based codes

First 25 sq cmCPT 15271 — application of skin substitute graft; covers up to first 25 sq cm of wound surface area

Each additional 25 sq cmCPT 15272 — billed for each additional 25 sq cm wound surface area, or part thereof (list separately in addition to primary procedure)

Code contextCodes 15271 and 15272 are listed among applicable procedure codes for reconstructive breast surgery

Autologous fat grafting — injectate volume codes

Up to 50 cc injectateCPT 15771 — grafting of autologous fat by liposuction technique; 50 cc or less injectate

Each additional 50 cc

Provider Requirements and Prior Authorization Guidance

Prior Authorization

State-specific coverage and prior authorization

Coverage for services described in this policy is governed by Louisiana Medicaid requirements. Prior authorization and coverage determinations must follow applicable federal, state, and contractual requirements; inclusion of procedure or diagnosis codes in this document is for reference only and does not guarantee payment or authorization.

State: Louisiana Medicaid governs coverage and prior authorization requirements
Procedure/diagnosis codes listed are illustrative and do not ensure coverage or reimbursement

Documentation Required

Required medical records

Providers must ensure medical record documentation fully supports the medical necessity of requested services. Documentation should be legible, maintained in the patients medical record, and made available upon request to support reviews and any prior authorization requests.

Include relevant history, physical examination findings, and results of pertinent diagnostic tests or procedures

Clinical Background

The purpose of reconstructive breast surgery is to restore breast form and symmetry after a therapeutic intervention (for example, mastectomy) or trauma that results in significant loss of breast tissue. Covered reconstructive services may include reconstruction of the affected breast, reconstruction of the contralateral breast for symmetry, provision of prostheses (implanted or external), and treatment of complications related to reconstruction. All prosthetic implants must be FDA-approved and used in accordance with FDA requirements at the time of surgery.

Definitions and Terms

Reconstructive breast surgery — definition & scope

DefinitionReconstructive breast surgery: surgery performed to rebuild the breast following a therapeutic intervention (e.g., mastectomy) or trauma resulting in significant loss of breast tissue

Scope — affected and contralateral breastsIncludes reconstruction of the affected breast and reconstruction of the contralateral breast to produce a symmetrical appearance

Scope — prostheses and complication managementIncludes prostheses (implanted or external, or both) and treatment of complications of the reconstruction; all prosthetic implants must be FDA approved and used in compliance with FDA requirements at the time of surgery

Acellular dermal matrix (ADM) — definition & FDA context

DefinitionAcellular dermal matrix (ADM): biologic implant products used for soft tissue reinforcement in implant-based reconstruction

Policy Revision and Retirement

2026-04-01retirementLatest

Policy retired; Louisiana plan membership disenrolled on April 1, 2026.

2025-11-01material_update

Added medical records documentation language requiring that the patient’s medical record contain documentation (history, physical exam, and pertinent diagnostic test results) that fully supports medical necessity and be made available upon request.