UnitedHealthcare Breast Reconstruction Policy Update

Coverage Criteria

Medical necessity governance

Medical necessity criteria are based on the North Carolina Medicaid Clinical Coverage Policy:

Reference to external NC Medicaid criteria: For medical necessity clinical coverage criteria, refer to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Physician: 1A-12, Breast Surgeries.

This policy defers to the specified NC Medicaid policy for detailed medical necessity criteria.

Covered indications

Covered indications for treatment of post-mastectomy complications and reconstructive goals:

Covered post-mastectomy complications: Treatment for complications post mastectomy are covered and considered medically necessary for lymphedema (including complex decongestive physiotherapy, lymphedema pumps, compression lymphedema sleeves, and elastic bandages/wraps associated with medically necessary lymphedema treatment) and for post-operative infection(s).

Includes lymphedema-related durable medical equipment and prosthetic devices as noted.

Reconstructive indications: Reconstructive breast surgery to restore appearance after lumpectomy or mastectomy is covered; reconstruction may be immediate or delayed. Indications also include non–breast cancer conditions such as Poland syndrome, radiation- or trauma-related disfigurement, and removal of breast implants with or without capsulectomy/capsulotomy.

May include contra-lateral procedures (e.g., mastopexy) as part of reconstruction.

Codes in the applicable code lists that are marked with an asterisk (*) are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the North Carolina Medicaid Program. Verify coverage when submitting claims or prior authorization requests for any asterisked codes (for example, *L8600, *S2066–S2068, *S8950).

This policy is specific to UnitedHealthcare members in North Carolina; always confirm member benefit terms and state fee-schedule applicability before rendering services or billing.

The U.S. Food and Drug Administration has noted that no acellular dermal matrix (ADM) products are FDA-cleared or approved specifically for use in breast reconstruction. On March 31, 2021 the FDA issued a safety advisory stating that certain ADM products used off‑label in implant-based breast reconstruction may have a higher risk of complications compared with other surgical mesh materials.

Clinicians and billing staff should be aware that ADM use in breast reconstruction is an off‑label application and potential safety differences across ADM products have been reported; consult the FDA link in the policy for details and consider these advisories when documenting medical necessity and obtaining consent.

When requesting coverage for reconstructive procedures or post‑mastectomy complication treatment, include complete, legible medical records that document the clinical indication, prior treatments, and rationale for the requested service. Coverage determinations are governed by applicable federal, state or contractual requirements and may differ from the clinical criteria in this policy; verification of member benefits and any required prior authorization is recommended prior to treatment.

Coding and Billing

Covered CPT Codes (partial listing)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 (i.e., breast, trunk) (List separately in addition to code for primary procedure).

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Covered CPT Codes (continued)CPT

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.
19364	Breast reconstruction; with free flap (e.g., fTRAM, DIEP, SIEA, GAP flap).
19367	Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap.
19368	Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging).
19369	Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap.
19370	Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy.

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HCPCS / Proprietary codes (some not on NC Medicaid fee schedule)HCPCS

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.

ICD-10 Diagnosis Codes (partial listing)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	Anaplastic large cell lymphoma, ALK-negative, breast.
D05.11	Intraductal carcinoma in situ of right 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.
Z90.11	Acquired absence of right breast and nipple.

Removed CPT CodesCPTNot Covered

19380

CPT code 19380 (removed from policy)

Affected/Referenced Codesmixed

affected codes

Prior authorization/coverage determined per benefit terms

State fee schedule availability

State fee schedule noteCodes marked with an asterisk (*) are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program.

Examples of affected codesHCPCS/proprietary codes listed with an asterisk in this policy: L8600, S2066, S2067, S2068, S8950.

Implication for claimsAbsence from the NC Medicaid fee schedule means the state program may not reimburse these codes even if the policy references them; verify state coverage prior to submission.

Provider Actions and Requirements

Prior Authorization

Prior Authorization May Be Required

Prior authorization may be required for listed CPT/HCPCS procedures. Verify PA requirements with member's benefit plan prior to scheduling.

Affected codes: see Applicable Codes section (policy includes CPT codes such as 11920–11922, 11970–11971, 15271–15272, 15771–15772, 15777, 19316–19371, 19370, 19396, 19499).
Prior authorization and benefit verification are plan- and state-specific; check federal/state/contractual requirements.

Prior Authorization

Prior Authorization and Benefit Verification

Prior authorization and benefit verification decisions are determined by the member’s benefit terms and applicable federal/state/contractual requirements. In case of conflict, federal/state/contractual requirements govern.

Confirm coverage and any PA rules before services are rendered.
Eligibility and benefit limits may vary by plan and state.

Background

Reconstructive breast surgery is performed to restore the appearance of the breast after lumpectomy or mastectomy and may also address congenital or trauma‑related deformities. Reconstruction can be performed immediately at the time of mastectomy (implant placement on the same day) or delayed until after completion of adjuvant therapy or when clinically appropriate.

Indications covered under this policy include restoration of form following oncologic surgery, treatment of post‑mastectomy complications (for example, lymphedema and postoperative infections), and removal of implants with or without capsulectomy/capsulotomy. The timing (immediate vs delayed) should be documented in the medical record and supported by clinical rationale.

Definitions

Mastectomy

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

Variation noteThere are different types of mastectomy that differ in the amount of tissue and lymph nodes removed (NCI, 2018).

Use in policyReferenced as the index procedure after which reconstructive services and treatment of complications (e.g., lymphedema) may be covered.

Acellular Dermal Matrix (ADM)

ADM regulatory statusThe FDA has not cleared or approved any acellular dermal matrix (ADM) products for use in breast reconstruction.

Safety advisoryOn March 31, 2021, the FDA issued a safety advisory noting certain ADM products may have higher complication rates when used off-label for implant-based breast reconstruction.

OpenPayer

Breast Reconstruction (for North Carolina Only)

Coverage Criteria

Coding and Billing

Provider Actions and Requirements

Background

Definitions