ModifiedUnitedHealthcarePolicy CS011TN.T

Breast Reconstruction (for Tennessee Only)

Policy governing coverage and clinical criteria for breast reconstruction, related procedures, and complications for Tennessee Medicaid and CoverKids members.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reconstruction (for Tennessee Only)

Policy CodePolicy CS011TN.T

Change TypeAdded medical-records documentation requirementsclarifications and reference updates

Effective DateNov 1, 2025

Next Review Date

Key ActionObtain prior authorization when required and ensure the patient's medical record fully documents medical necessity and is available upon request.

SourceLink

POLICY UPDATE CHANGES

Medical records documentation language was added specifying that documentation may be required to assess whether the member meets clinical criteria and must fully support medical necessity.

Added language clarifying that medical records documentation may be required to assess whether the member meets clinical criteria for coverage and does not guarantee coverage.

Added requirement that the patient's medical record must contain documentation that fully supports the medical necessity for the requested services.

Clarified that benefit coverage is determined by federal, state, or contractual requirements and applicable laws which may supersede policy content.

Updated Clinical Evidence and References sections to reflect current information; archived previous policy version CS011TN.S.

11/01/2025effective date of latest revision

5 yearscontralateral symmetry timeframe

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.

clinical criteria referenced

Tennesseestate-specific

Numerouscodes listed

Coverage Criteria and Definitions

Medically necessary indications and associated procedures — InterQual reference

Medically necessary indications and associated procedures — refer to InterQual clinical criteria. The following criteria summarize reconstructive versus cosmetic distinctions and list associated procedures that may be considered reconstructive when performed with breast reconstruction.

ALL of the following

Breast reconstruction during or after mastectomy, or for treatment of a congenital disorder (e.g., Poland syndrome, Turner syndrome) or severe breast disfigurement (e.g., amastia, radiation) is considered reconstructive and may be medically necessary. For detailed clinical criteria, refer to the InterQual® CP: Procedures, Breast Reconstruction.
Associated procedures that may be considered reconstructive when performed with a breast reconstructive procedure:
- Creation of a nipple (by various techniques) and areola (tattooing).
- Mastopexy or breast reduction when required prior to mastectomy to preserve nipple viability.
- Reconstruction with a breast implant may be considered reconstructive and medically necessary with or without:
  - Implantation of a tissue expander as the initial phase of reconstruction.
  - Use of an Acellular Dermal Matrix (ADM), including but not limited to AlloDerm™, Cortiva®, AlloMax™, DermACELL, or FlexHD.
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). Removal may be with or without capsulectomy/capsulotomy per clinical criteria; refer to InterQual® CP: Procedures, Breast Implant Removal.
Breast repair and reconstruction procedures not post-mastectomy may be considered reconstructive and medically necessary for correction of inverted nipples when one of the following is met:
- Documented history of chronic nipple discharge, bleeding, scabbing, or ductal infection.
- Correction of inverted nipple(s) resulting from a congenital anomaly.
Surgical procedure performed on a non-diseased breast to establish symmetry with the diseased breast is covered only if performed within five (5) years of the reconstructive breast surgery on the diseased breast (see TennCare Medicaid, Chapter 1200-13-13-.04).

Coverage and Exclusions

Coverage and exclusions — coverage is subject to federal, state, and contractual requirements and adequate documentation. A gap exception may be granted if no in-network provider is available to provide the requested reconstructive procedure.

ALL of the following

Benefit coverage is determined by federal, state, and contractual requirements; these requirements may supersede the criteria listed here.
Medical records documentation may be required to assess whether the member meets clinical criteria for coverage. Documentation must fully support medical necessity and include relevant history, physical exam, and results of pertinent diagnostic tests or procedures. Documentation should be legible, maintained in the medical record, and made available upon request.
A gap exception may be granted when an in-network provider is not available to perform the requested reconstructive procedure.

Coverage Criteria (referenced)

Coverage Criteria (placeholder) — consult the full policy and InterQual criteria for the complete, detailed coverage criteria used to determine medical necessity.

ANY of the following

Use InterQual® CP: Procedures, Breast Reconstruction for the definitive, itemized clinical coverage criteria applied during utilization review and medical necessity determinations.
Use InterQual® CP: Procedures, Breast Implant Removal for implant removal specific criteria.
Clinical review requires medical record documentation as described above; meeting InterQual criteria does not guarantee coverage if federal, state, or contractual exclusions apply.

Procedure, HCPCS and Diagnosis Codes

Covered CPT Codes (selection, part 1)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...; 6.1 to 20.0 sq cm.
11922	Tattooing...; each additional 20.0 sq cm, or part thereof.
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... each additional 25 sq cm wound surface area, or part thereof.
15771	Grafting of autologous fat...; 50 cc or less injectate.
15772	Grafting of autologous fat... each additional 50 cc injectate, or part thereof.
15777	Implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement.

Covered CPT Codes (selection, part 2)CPTCovered

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).
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).

1–10 of 18

1/2

HCPCS/Special CodesHCPCSCovered

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 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.
I97.2	Postmastectomy lymphedema syndrome.
N65.0	Deformity of reconstructed breast.
T85.43XA	Leakage of breast prosthesis and implant, subsequent encounter.
Z42.1	Encounter for breast reconstruction following mastectomy.
Z90.11	Acquired absence of right breast and nipple.

Codes referenced (none in this fragment)mixed

No specific CPT/HCPCS/ICD-10 codes are listed in this document fragment.

Contralateral symmetry surgery timeframe

TimeframeSurgical procedure on a non-diseased breast to establish symmetry is covered only if performed within five (5) years of the date the reconstructive breast surgery was performed on the diseased breast.

ReferenceRefer to TennCare Medicaid, Chapter 1200-13-13-.04: Covered Services.

ApplicabilityApplies when symmetry procedure is performed in connection with reconstructive breast surgery as defined in policy.

Miscellaneous coding note

Coding noteApplicable procedure codes for reconstruction-related tattooing, tissue expander management, ADM implantation and related services are listed in the coding section (e.g., 11920, 11970, 15777).

Provider Responsibilities, Prior Authorization & Documentation

Prior Authorization

Prior Authorization Required

Prior authorization may be required for the procedures listed in this policy and is determined using InterQual® clinical criteria. Providers should obtain any required prior authorization before scheduling or performing services.

Prior authorization per InterQual® for listed procedure codes
Intraoperative assessment of vascular perfusion is considered integral to reconstruction and is not separately reimbursable

Note

Coverage Determination & Gap Exception

Benefit coverage is governed by federal, state, and contractual requirements. If no in-network provider is available to perform the requested reconstructive procedure, a gap exception may be granted. Cosmetic procedures (see examples below) are excluded and may be denied if billed as reconstructive.

Gap exception may be granted when no in‑network reconstructive provider is available
Procedures that correct a congenital anomaly without restoring physiologic function are cosmetic and excluded

Background and Clinical Context

Background: Breast reconstruction aims to restore breast appearance following lumpectomy, mastectomy, congenital anomaly, radiation injury, or trauma. Reconstruction can be immediate or delayed and commonly includes implant-based or autologous flap procedures, nipple/areola creation (including tattooing), and the use of acellular dermal matrix as part of implant reconstruction. Coverage for reconstruction and related procedures is determined when the InterQual® clinical criteria for breast reconstruction are met and when documentation supports medical necessity.

Definitions and Abbreviations

Acellular Dermal Matrix (ADM)

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

Use in reconstructionADM may be used as part of reconstruction with a breast implant or tissue expander (e.g., AlloDerm™, Cortiva®, AlloMax™, DermACELL, FlexHD).

RoleConsidered part of the reconstructive procedure when used with breast reconstruction per policy.

Anaplastic Lymphoma

DefinitionAnaplastic Lymphoma: a rare type of non-Hodgkin lymphoma (NHL), one of the T‑cell lymphoma subtypes; comprises about 1% of all NHLs and ~16% of T‑cell lymphomas.

Presentation (breast implant–associated)Breast implant–associated anaplastic large cell lymphoma most commonly presents as a delayed fluid collection around a textured implant or as a mass in the fibrous capsule surrounding the implant.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reconstruction (for Tennessee Only)

Policy CodePolicy CS011TN.T

Change TypeAdded medical-records documentation requirementsclarifications and reference updates

Effective DateNov 1, 2025

Next Review Date

Key ActionObtain prior authorization when required and ensure the patient's medical record fully documents medical necessity and is available upon request.

SourceLink

On This Page

Billing reminderLists of codes are for reference and may not be all inclusive; verify applicable plan requirements and prior authorization rules before billing.

Prior authorizationProviders should obtain prior authorization when required per plan for listed procedure codes referenced by InterQual.

Examples of excluded cosmetic procedures: mastopexy, breast augmentation, liposuction, nipple/areolar procedures not related to mastectomy

Note

Verify Applicable Benefit Requirements

Verify the member's applicable benefit plan, including federal, state, and contractual requirements, before applying this policy. In the event of a conflict, the federal, state, or contractual requirements govern coverage decisions.

Check member-specific plan language and state/federal mandates prior to authorization or claim submission
If plan terms differ from this policy, plan terms take precedence

Denial Risk

Documentation Insufficiency Risk

The patient's medical record must contain documentation that fully supports the medical necessity for the requested services. Failure to provide sufficient documentation may result in denial of the request.

Insufficient or illegible records may lead to denial
Documentation provided to support clinical criteria does not guarantee coverage

Documentation Required

Medical Records Required for Review

Medical records may be required to assess whether the member meets the clinical criteria for coverage. Required documentation includes, but is not limited to, relevant medical history, physical examination, diagnostic test results, pathology/operative notes, and imaging. Records must be legible, maintained in the patient's medical record, and made available upon request.

Relevant medical history and physical exam
Pertinent diagnostic test results and imaging
Pathology reports and operative notes
Documentation demonstrating medical necessity for requested procedure

Clinical noteAssociated with textured implant surfaces and has been reported with both silicone and saline implants.

Congenital Anomaly

DefinitionCongenital Anomaly: a physical developmental defect present at birth and identified within the first twelve months of life.

Coverage implicationProcedures that correct a congenital anomaly are considered reconstructive when they improve or restore physiologic function; those that do not are considered cosmetic and excluded.

ExampleConditions such as Poland syndrome or amastia may be indications for reconstructive coverage per policy and InterQual criteria.

Mastectomy

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

Reconstructive contextBreast reconstruction during or after mastectomy is a covered reconstructive indication when InterQual clinical criteria are met.

Related proceduresReconstruction may include immediate implant placement, tissue expanders, ADM use, nipple/areola creation, and autologous flap procedures.

Mastopexy/Breast Lift

DefinitionMastopexy/Breast Lift: a procedure that raises the breast, removes excess skin, and tightens surrounding tissue.

Reconstructive roleMastopexy may be considered part of reconstruction when required prior to mastectomy to preserve nipple viability or when performed with reconstructive procedures.

Cosmetic exclusionWhen performed solely for breast enhancement or symmetry unrelated to mastectomy, mastopexy is considered cosmetic and excluded from coverage.

BIA-ALCL

DefinitionBreast Implant‑Associated Anaplastic Large Cell Lymphoma (BIA‑ALCL): a T‑cell non‑Hodgkin lymphoma that can develop around breast implants, most commonly textured surfaces.

AssociationsHas been reported with both silicone and saline implants and in reconstructive and cosmetic settings; exact pathogenesis is unclear.

Clinical implicationPolicy notes increased risk with textured implants and supports implant removal as reconstructive for individuals with Allergan BIOCELL textured implants regardless of reason for initial placement.

Cosmetic (for breast reconstruction)

DefinitionCosmetic (for breast reconstruction): a procedure that corrects an anatomical congenital anomaly without improving or restoring physiologic function and is excluded from coverage.

Examples of cosmetic exclusionsIncludes breast enhancement (implants, mastopexy), liposuction, aspirations, biopsies, excision of cysts, fibroadenomas, nipple/areolar lesion procedures when not related to mastectomy.

Symmetry proceduresBreast surgery performed solely to create symmetry is excluded when not related to mastectomy; contralateral symmetry may be covered if within 5 years of reconstructive surgery on the diseased breast.

InterQual

DefinitionInterQual: a third‑party clinical decision support tool UnitedHealthcare may use to assist in administering health benefits and for clinical criteria reference (e.g., InterQual CP: Procedures, Breast Reconstruction).

UseUnitedHealthcare references InterQual criteria to determine medical necessity for breast reconstruction procedures and related services.

Provider actionProviders should refer to InterQual criteria and obtain prior authorization when required per plan for the listed procedure codes.