UnitedHealthcare Breast Reconstruction Coverage Update

Coverage Criteria

Medically Necessary/Reconstructive

Covered when ALL of the following contextual conditions are met:

Other reconstructive indications: Breast reconstruction during or post-mastectomy and reconstruction for treatment of congenital disorders (e.g., Poland syndrome, Turner syndrome) or severe breast disfigurement (e.g., amastia, radiation-related deformity) are considered reconstructive and medically necessary in certain circumstances.

Adjunct procedures when performed with reconstruction: Creation of a nipple and areola (including tattooing), mastopexy or breast reduction when required prior to mastectomy to preserve nipple viability, reconstruction with implant or tissue expander, and use of an acellular dermal matrix (ADM) are considered reconstructive when performed with a breast reconstructive procedure.

Medically necessary reconstructive indications

Covered when ALL of the following are met

Non-cancer reconstructive indications: Reconstruction for congenital anomalies (e.g., Poland syndrome), trauma, radiation-related disfigurement, and removal of implants with or without capsulectomy/capsulotomy are considered reconstructive and eligible for coverage.

Breast reconstruction performed solely to correct asymmetry is considered cosmetic and not medically necessary when it is not associated with a mastectomy, congenital disorder, or severe disfigurement. The policy specifies that reconstruction for asymmetry outside the listed reconstructive indications will be treated as cosmetic and may be denied; see Benefit Considerations for applicable exceptions when reconstruction is related to mastectomy or recognized reconstructive diagnoses.

When asymmetry procedures are performed in conjunction with a covered breast reconstructive procedure (for example, as part of post‑mastectomy reconstruction or to achieve symmetry between the reconstructed and contralateral breast), those procedures may be considered reconstructive and medically necessary according to the policy and applicable benefit provisions.

The policy excludes from coverage certain procedures that are cosmetic when not related to mastectomy. Specifically, breast enhancement such as breast implants and mastopexy (breast lift) for enhancement purposes, as well as liposuction, are listed as cosmetic and therefore not covered when they are not performed in connection with a mastectomy or other covered reconstructive indication.

Also excluded are surgeries performed solely to create symmetry that are unrelated to a covered reconstructive indication; these procedures may be denied if submitted as reconstructive services under the policy.

Procedures performed solely to address asymmetry in the absence of a mastectomy, congenital anomaly requiring reconstruction, or severe disfigurement are considered not medically necessary (cosmetic). Such interventions do not meet the policy’s reconstructive criteria and are excluded from coverage.

Providers should document a covered reconstructive indication (for example, mastectomy, Poland syndrome, or other specified diagnoses) when billing for procedures intended to address symmetry; without that documentation, claims for asymmetry correction may be denied as cosmetic.

Breast reconstruction performed solely for cosmetic reasons—including augmentation, mastopexy for enhancement, and revisions performed because of normal aging—is considered not medically necessary and excluded from coverage. The policy clarifies that procedures correcting an anatomical congenital anomaly that do not restore or improve physiologic function are likewise cosmetic and excluded.

If reconstruction is being sought for appearance alone and does not meet the reconstructive definitions or recognized indications (e.g., post‑mastectomy reconstruction, treatment of physical complications of mastectomy, or specific congenital deformities), the procedure will not be covered under this policy.

Coding and Billing

Applicable CPT/Procedure Codes (part 1)CPT

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 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 (breast, trunk) (List separately in addition to code for primary procedure).

Applicable CPT/Procedure Codes (part 2)CPT

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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Applicable HCPCS/Supplemental CodesHCPCS

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 Diagnosis Codes (partial list)ICD-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.

Applicable ICD-10 Diagnosis CodesICD-10

C50.321	Malignant neoplasm of lower-inner quadrant of right male breast
C50.322	Malignant neoplasm of lower-inner quadrant of left male breast
C50.329	Malignant neoplasm of lower-inner quadrant of unspecified male breast
C50.411	Malignant neoplasm of upper-outer quadrant of right female breast
C50.412	Malignant neoplasm of upper-outer quadrant of left female breast
C50.419	Malignant neoplasm of upper-outer quadrant of unspecified female breast
C50.421	Malignant neoplasm of upper-outer quadrant of right male breast
C50.422	Malignant neoplasm of upper-outer quadrant of left male breast
C50.429	Malignant neoplasm of upper-outer quadrant of unspecified male breast
C50.511	Malignant neoplasm of lower-outer quadrant of right female breast

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Tattoo area thresholds — CPT mapping

CPT 11920Tattooing; intradermal pigments to correct color defects — area 6.0 sq cm or less

CPT 11921Tattooing; intradermal pigments to correct color defects — area 6.1 to 20.0 sq cm

CPT 11922Tattooing; intradermal pigments to correct color defects — each additional 20.0 sq cm (list separately)

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required: InterQual-based prior authorization is required for breast reconstruction, implant removal, and related procedures. Refer to the InterQual CP criteria for Procedures, Breast Reconstruction and for Breast Implant Removal when submitting requests.

Applies to reconstruction after mastectomy, reconstruction for congenital disorders or severe disfigurement, and removal of Allergan® BIOCELL textured implants.
Include supporting documentation per InterQual criteria (operative reports, pathology, imaging, prior treatment records).

Prior Authorization

Prior Authorization and Gap Exception

Prior authorization may be required per the member’s benefit plan; check the member-specific plan document. A gap exception may be granted if no in-network provider can provide the requested reconstructive procedure.

Verify in-network provider availability before requesting gap exception.
Document attempts to identify in-network providers when requesting a gap exception.

Background

Breast reconstruction after mastectomy is recognized as a reconstructive, medically necessary service under the Women’s Health and Cancer Rights Act of 1998. The policy explicitly covers reconstruction of the breast on which a mastectomy was performed, reconstruction of the contralateral breast and nipple tattooing to achieve symmetry, prostheses, and treatment of physical complications of mastectomy such as lymphedema.

In addition to cancer‑related mastectomy, reconstruction is considered reconstructive and eligible for coverage for certain non‑cancer indications (for example, Poland syndrome, congenital anomalies, trauma, or radiation‑related disfigurement) and may include adjunct procedures—such as nipple/areola creation (including tattooing), mastopexy or breast reduction when required prior to mastectomy, use of tissue expanders, implants, or Acellular Dermal Matrix (ADM)—when performed as part of the reconstructive plan.

Definitions

Acellular Dermal Matrix (ADM)

DefinitionAcellular Dermal Matrix (ADM) is a type of surgical mesh developed from human or animal skin in which cells are removed and the support structure is left in place (FDA, 2021).

Typical useUsed as a biologic implant for soft-tissue reinforcement during breast reconstruction (e.g., implant-based reconstruction, tissue expander procedures).

Regulatory/source noteDescribed in policy definitions as an FDA-recognized biologic mesh product (2021 reference).

Anaplastic Lymphoma

DefinitionAnaplastic Lymphoma: a rare type of non-Hodgkin lymphoma and a subtype of T‑cell lymphoma; comprises ~1% of all NHLs and ~16% of T‑cell lymphomas.

Common presentation (breast implant–associated)

OpenPayer

Breast Reconstruction (post‑mastectomy and related procedures)

Coverage Criteria

Coding and Billing

Provider Actions and Requirements

Background

Definitions