ModifiedUnitedHealthcarePolicy CS011NM.C

Breast Reconstruction (for New Mexico Only)

Defines medical necessity and coverage for reconstructive breast surgery and associated procedures for UnitedHealthcare members in New Mexico, including post-mastectomy reconstruction, congenital anomalies, and certain implant removals.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reconstruction (for New Mexico Only)

Policy CodePolicy CS011NM.C

Change TypeDocumentation and reference updates

Effective DateNov 1, 2025

Next Review Date

Key ActionObtain and maintain legible medical record documentation that fully supports medical necessity, including history, physical exam, and relevant diagnostic test results; prior authorization is expected for reconstructive procedures and device use.

SourceLink

POLICY UPDATE CHANGES

Added language clarifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records documentation may be required to assess clinical criteria for coverage.

Specified that the patient's medical record must contain documentation that fully supports the medical necessity for the requested services, including history, exam, and diagnostic test results.

Updated Clinical Evidence and References sections to reflect the most current information.

state-specificpolicy applies only to New Mexico

InterQualInterQual referenced

CPT/HCPCS/ICDcodes listed

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

coveredAllergan BIOCELL implant removals

excludedcosmetic exclusions enumerated

multipleliterature cited

Coverage and Medical Necessity Criteria

Medically necessary indications

Covered when criteria below are met or per InterQual CP where referenced

Primary indications: Breast reconstruction is considered reconstructive and medically necessary for breast reconstruction during or after mastectomy, for treatment of congenital disorders (e.g., Poland syndrome, Turner syndrome), or severe breast disfigurement (e.g., amastia, radiation).

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

Associated procedures considered reconstructive: Creation of nipple and areola (including tattooing), mastopexy or breast reduction when required prior to mastectomy to preserve nipple viability, reconstruction with breast implant (including tissue expander use) and use of Acellular Dermal Matrix may be considered reconstructive and medically necessary when performed with a breast reconstructive procedure.

ADM examples include AlloDerm, Cortiva, AlloMax, DermACELL, FlexHD.

Implant removal: Removal of breast implants is considered reconstructive and medically necessary for individuals implanted with Allergan BIOCELL textured implants regardless of reason for initial placement due to increased risk of implant-associated anaplastic large cell lymphoma; removal may be with or without capsulectomy/capsulotomy per InterQual criteria.

Refer to InterQual CP: Procedures, Breast Implant Removal for medical necessity criteria.

Post-mastectomy complications: Treatment for complications after mastectomy such as lymphedema (including complex decongestive physiotherapy, lymphedema pumps, compression sleeves) and postoperative infections are covered and medically necessary.

Lymphedema pumps considered durable medical equipment; compression sleeves considered prosthetic devices.

Inverted nipple correction: Correction of inverted nipples (not post-mastectomy) is medically necessary when there is documented chronic nipple discharge, bleeding, scabbing, or ductal infection, or when the inversion results from a congenital anomaly.

Not medically necessary (cosmetic)

Cosmetic exclusion: Breast reconstruction for asymmetry for all other indications is considered cosmetic and not medically necessary.

Refer to Benefit Considerations.

Medically necessary reconstructive indications

Covered when reconstructive intent is present (examples provided in text).

General reconstructive indications: Reconstructive breast surgery is covered when performed to restore appearance after lumpectomy or mastectomy for breast cancer, for Poland syndrome and other disorders causing breast disfigurement, for disfigurement caused by radiation or trauma, and for removal of breast implants with or without capsulectomy/capsulotomy.

Reconstruction may be immediate or delayed until completion of adjuvant therapy or patient decision; contralateral mastopexy for symmetry may be included.

Cosmetic exclusions / Not medically necessary

Not covered when performed solely for cosmetic reasons:

Cosmetic exclusions: Procedures that correct an anatomical congenital anomaly without improving or restoring physiologic function and the following are considered cosmetic and 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'/standing cone). Additionally, when not related to mastectomy, the following are excluded: breast enhancement (e.g., implants, mastopexy), liposuction, and breast surgery solely to create symmetrical breasts.

Painful scars or donor site scar revisions must meet the definition of a reconstructive procedure to be considered for coverage.

Non-surgical lymphedema treatment

Conservative management for lymphedema:

Conservative lymphedema care: Complex decongestive therapy (CDT) and use of compression garments are supported interventions to improve health-related quality of life and to prevent progression in mild breast cancer–related upper limb lymphedema; lymphedema pumps and compression sleeves are included as covered interventions in this conservative management approach.

Evidence is heterogeneous; some reviews exclude manual lymphatic drainage and garment impact is variably reported.

Breast reconstruction performed solely to correct asymmetry without any other reconstructive indication is considered cosmetic and not medically necessary. Refer to Benefit Considerations and InterQual criteria for situations in which symmetry procedures may be considered part of a reconstructive plan.

Examples of procedures that are considered cosmetic and excluded from coverage when not related to mastectomy include breast enhancement (such as elective implants or augmentation), liposuction, and mastopexy performed for aesthetic improvement. The policy also excludes breast surgery performed solely for the purpose of creating symmetrical breasts when not part of reconstructive care. Conversely, procedures performed with or as part of a breast reconstruction (for example, nipple creation/tattooing, mastopexy or reduction required prior to mastectomy, implant-based reconstruction with tissue expander or use of an Acellular Dermal Matrix) may be considered reconstructive and medically necessary when done in conjunction with a covered reconstructive procedure.

This Medical Policy is provided for informational purposes to assist in interpreting UnitedHealthcare standard benefit plans. When determining coverage, federal, state, or contractual benefit plan requirements take precedence and must be consulted where they differ from this policy. UnitedHealthcare may use third-party tools (for example, InterQual®) to assist in benefit determinations; the policy does not itself guarantee coverage and does not constitute medical advice.

Procedures performed solely to correct asymmetry—that is, without other reconstructive indications such as post-mastectomy reconstruction, congenital anomalies, or treatment of deformity from trauma or radiation—are considered cosmetic and are not medically necessary. Documentation should demonstrate reconstructive intent when symmetry procedures are part of a broader reconstructive plan.

Reconstruction performed solely for cosmetic reasons is excluded from coverage. The policy explicitly lists excluded cosmetic indications, including correction of aberrant breast tissue, aspirations, biopsies, excision of cysts or benign lesions, nipple/areolar lesions, treatment of gynecomastia, revision of a previously reconstructed breast for normal aging, ‘‘dog ear’’ scar revisions (unless meeting reconstructive criteria), and cosmetic procedures not related to mastectomy such as breast augmentation, liposuction, or surgery solely to create symmetry.

Applicable Codes

Covered 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.
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 / S 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.

ICD-10 Diagnosis CodesICD-10

C50.011	Malignant neoplasm of nipple and areola, right 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.
Q79.8	Other congenital malformations of musculoskeletal system.
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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Applicable ICD-10 Diagnosis CodesICD-10

Z90.10	Acquired absence of unspecified breast and nipple.
Z90.11	Acquired absence of right breast and nipple.
Z90.12	Acquired absence of left breast and nipple.
Z90.13	Acquired absence of bilateral breasts and nipples.

Prior Authorization, Documentation, and Billing Guidance

Note

Prior authorization and coding note

The following codes are provided for reference only and do not guarantee coverage or reimbursement. Inclusion in this policy does not imply the service is a covered benefit. Intraoperative assessment of vascular perfusion during breast reconstruction is considered an integral component of the procedure and is not separately reimbursable.

Coding Clarification: Intraoperative perfusion assessment is integral to reconstruction — not separately billable.

Prior Authorization

Prior Authorization Required for Reconstructive Procedures and Device Use

Prior authorization is typically required for reconstructive procedures involving implants, tissue expanders, and acellular dermal matrix (ADM) products. Providers should obtain prior authorization when implantable devices or staged reconstruction (e.g., tissue expander placement) are planned.

Prior authorization expected for breast implants, tissue expanders, and ADM products.
Gap exceptions may be available if no in-network provider can perform the reconstructive procedure.

Definitions

Acellular Dermal Matrix (ADM) — definition and short description

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 (extracellular) structure is left in place.

Common examples referenced in policyADM products referenced include AlloDerm, Cortiva, AlloMax, DermACELL, FlexHD.

Clinical roleUsed as a biologic scaffold in implant-based breast reconstruction to support soft tissue reinforcement and implant positioning.

Evidence noteRecent meta-analyses and RCTs report comparable short- and long-term postoperative outcomes between ADM and non-ADM reconstructions, but patient-reported outcomes data are limited.

Anaplastic Lymphoma — definition (implant-associated form noted)

Definition

Background

Reconstructive breast surgery restores breast appearance after lumpectomy or mastectomy and may be performed immediately or delayed after completion of cancer therapy or by patient choice. Indications for reconstruction include restoration after cancer surgery, congenital disorders (for example, Poland syndrome), severe disfigurement from radiation or trauma, and removal of implants when clinically indicated. Certain adjunctive procedures—such as nipple and areola creation (including tattooing), mastopexy or breast reduction when required to preserve nipple viability prior to mastectomy, implant-based reconstruction using tissue expanders, and use of Acellular Dermal Matrix—may be considered reconstructive when performed in conjunction with a covered reconstructive procedure. Benefit plan, federal, state, or contractual requirements govern coverage determinations and should be referenced as they may supersede this policy.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reconstruction (for New Mexico Only)

Policy CodePolicy CS011NM.C

Change TypeDocumentation and reference updates

Effective DateNov 1, 2025

Next Review Date

SourceLink

On This Page

Note

Check Plan Requirements and Potential Use of Utilization Tools

Benefit coverage is determined by federal, state, and contractual requirements; check the applicable plan language before rendering services. UnitedHealthcare may use third‑party utilization review tools (e.g., InterQual®) to assist in coverage determinations. Contact the member’s plan or use the payer’s provider portal to confirm plan-specific prior authorization, precertification, or utilization management requirements.

Confirm federal/state/contractual requirements that may supersede this policy.
UnitedHealthcare may apply InterQual® or other utilization tools in coverage reviews.

Documentation Required

Medical Records Requirements

The patient's medical record must contain legible documentation that fully supports the medical necessity of the requested service. Documentation should include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures. Maintain and provide records upon request to support any clinical criteria used in coverage determinations.

Include history, physical exam, imaging, pathology, and any relevant consult notes.
Ensure documentation clearly supports reconstructive intent and physiologic benefit when applicable.

Denial Risk

Documentation Sufficiency

Documentation must be sufficient to substantiate the medical necessity of the requested service. Lack of adequate documentation may result in denial or a non‑coverage determination. Ensure records clearly explain the clinical problem, previous conservative measures tried (if applicable), rationale for surgery or device use, and goals expected to improve or restore physiologic function.

Insufficient or illegible records may lead to claim denial.
When requesting reconstructive services, explicitly document functional impairment or physiologic dysfunction to distinguish from cosmetic indications.

Documentation Required

Conservative Therapy Recommended for Lymphedema

Conservative (non‑surgical) therapy is recommended as first‑line management for lymphedema. Document trials of conservative measures such as fitted compression garments, complex decongestive therapy (CDT), self‑care education, and manual lymphatic drainage as appropriate. Early use of compression garments has evidence for preventing progression in mild breast cancer‑related lymphedema; CDT is commonly recommended for improving health‑related quality of life.

Recommend and document trial of compression garments and/or complex decongestive therapy before surgical interventions for lymphedema when clinically appropriate.
Evidence does not support laser therapy or electrical moxibustion for lymphedema management.

Anaplastic lymphoma is a rare subtype of T‑cell non‑Hodgkin lymphoma.

Implant‑associated formBreast implant–associated anaplastic large‑cell lymphoma (BIA‑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/clinical presentationBIA‑ALCL has been reported with both silicone and saline implants and can occur after reconstruction or cosmetic implantation; pathogenesis remains incompletely understood.

Congenital Anomaly — definition and timing

DefinitionA congenital anomaly is a physical developmental defect present at the time of birth and identified within the first twelve months of life.

Relevance to policy timingWhen congenital anomalies cause breast disfigurement (e.g., Poland syndrome), reconstructive procedures are considered medically necessary and may be performed in the pediatric or early postnatal period as clinically indicated.

Coverage implicationProcedures to correct congenital anomalies are eligible for reconstructive coverage when they restore appearance or function rather than solely for cosmetic reasons.

Mastectomy — definition and types

DefinitionMastectomy is surgery to remove all or part of the breast; types vary by the amount of breast tissue and lymph nodes removed.

Types/examplesExamples include partial (lumpectomy), total, skin‑sparing, nipple‑sparing, and procedures that differ by lymph node removal (as referenced to NCI guidance).

Relation to reconstructionReconstruction may be immediate (same day as mastectomy) or delayed until completion of adjuvant therapy or patient decision.

Mastopexy/Breast Lift — definition

DefinitionMastopexy (breast lift) is a surgical procedure that raises the breast, removes excess skin, and tightens surrounding tissue.

Role in reconstructionMastopexy to the contralateral breast may be performed as part of reconstructive surgery to achieve symmetry after mastectomy or reconstruction.

Cosmetic distinctionWhen performed solely for aesthetic breast enhancement not related to mastectomy or reconstruction, mastopexy is considered cosmetic and not medically necessary under this policy.

Breast reconstruction — definition and scope

DefinitionBreast reconstruction encompasses surgical procedures to restore the appearance of the breast after mastectomy, lumpectomy, trauma, radiation injury, congenital anomaly, or implant removal.

Scope of proceduresMay include implant‑based reconstruction (with tissue expanders/implants and possible ADM use), autologous flap reconstruction (e.g., TRAM, DIEP, GAP), nipple‑areola reconstruction, and contralateral procedures for symmetry.

TimingReconstruction can be immediate at the time of mastectomy or delayed until after adjuvant therapy or patient decision.

BIA-ALCL — definition (Breast Implant–Associated Anaplastic Large Cell Lymphoma)

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

Clinical featuresMost commonly presents as delayed seroma or a capsular mass; has been associated with both silicone and saline implants in reconstructive and cosmetic settings.

Evidence noteSystematic reviews and case series inform diagnosis, management, and risk stratification; ongoing research is needed to clarify pathogenesis and prevention.

Acellular Dermal Matrix (ADM) — note about off-label use and FDA clearance status

Regulatory statusThe FDA has not cleared or approved any ADM products specifically for use in breast reconstruction; use of ADM in this indication is off‑label.

FDA safety advisoryOn March 31, 2021, the FDA issued a safety advisory noting differing complication rates among ADM products when used in implant‑based breast reconstruction and advising caution.

Clinical implicationProviders should note device status and potential differing complication profiles when documenting medical necessity for ADM use in reconstruction.

Acellular dermal matrix (ADM) — additional definition referencing recent studies

Definition (expanded)Acellular dermal matrix (ADM) is a biologic scaffold derived from human or animal dermis used to support soft tissue and implants in breast reconstruction.

Comparative effectivenessA 2024 systematic review and meta‑analysis found no significant differences in common postoperative complications (seroma, hematoma, infection, wound dehiscence, reoperation, implant loss, skin necrosis) between ADM and non‑ADM reconstruction groups, though patient‑reported outcomes were inadequately studied.

Research limitationsLimitations include heterogeneity in ADM types, implant placement, and limited data on long‑term patient‑reported outcomes, indicating need for further research.

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) — rare complication definition

DefinitionBreast implant‑associated anaplastic large‑cell lymphoma (BIA‑ALCL) is a rare T‑cell non‑Hodgkin lymphoma that can develop around breast implants, most commonly textured‑surface implants.

Typical presentationCommon clinical presentations include a delayed seroma (fluid collection) around a textured implant or a mass within the fibrous capsule surrounding the implant.

Clinical and epidemiologic evidenceSystematic reviews and epidemiologic series inform current understanding of incidence, presentation, and management; ongoing research is emphasized in the literature.