Breast Reduction Surgery (for Idaho Only)
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Defines UnitedHealthcare Community Plan medical policy for breast reduction (reduction mammaplasty) that applies only in Idaho, including Idaho Medicaid Plus plans; references InterQual criteria for clinical coverage.
Applicable Codes section was added and instruction to refer to the Idaho Medicaid Provider Handbook for non-covered and excluded services was included.
Supporting Information section was updated with a References section referencing the Idaho Medicaid Provider Handbook.
Coverage Criteria
Medical necessity (InterQual-based)
Covered when ALL InterQual CP: Procedures, Reduction Mammaplasty, Female criteria are met.
Providers must reference the InterQual criteria for specific clinical requirements and thresholds and obtain prior authorization where required by plan rules.
This policy does not cover procedures related to gynecomastia. For reduction mammaplasty requests related to gynecomastia, refer to the Medical Policy titled Gynecomastia Surgery (for Idaho Only). In addition, providers should be aware of any applicable InterQual or state-specific requirements that may affect coverage determinations for these presentations.
This policy relies on the external InterQual® CP: Procedures, Reduction Mammaplasty, Female criteria to define medical necessity rather than listing internal non‑medically necessary (NMN) scenarios. When a situation is not explicitly addressed by this policy, coverage determinations will follow the referenced InterQual criteria and applicable state or contractual requirements (for example, the Idaho Medicaid Provider Handbook). No separate internal NMN list is provided in this policy.
Applicable Codes
| 19318 | Breast reduction |
| N65.1 | Disproportion of reconstructed breast |
Provider Actions and Requirements
InterQual-based medical necessity & prior authorization
Coverage for reduction mammaplasty is determined by the InterQual® CP: Procedures, Reduction Mammaplasty, Female; obtain prior authorization where required by the plan and reference the InterQual criteria when requesting coverage for CPT 19318.
- Reference InterQual CP: Procedures, Reduction Mammaplasty, Female for clinical criteria and thresholds.
- Obtain prior authorization per plan rules when submitting requests for CPT 19318.
Related policy & administrative referrals
Ensure all standard administrative and clinical provider responsibilities are followed for requests and reviews; consult related policies (Breast Reconstruction, Cosmetic and Reconstructive Procedures, Gynecomastia Surgery, Panniculectomy) and the Idaho Medicaid Provider Handbook for non-covered/excluded services as applicable.
- Refer reduction mammaplasty related to gynecomastia to the Gynecomastia Surgery (for Idaho Only) policy.
- Follow Idaho Medicaid Provider Handbook instructions for non-covered and excluded services.
Medical record documentation requirements
Maintain legible medical record documentation that fully supports medical necessity, including relevant history, physical examination, and results of pertinent diagnostic tests or procedures; records must be available upon request.
- Document relevant medical history and physical exam findings related to macromastia symptoms.
- Include results of pertinent diagnostic tests or procedures in the record.
Documentation may lead to denial if incomplete
Insufficient or missing documentation that does not fully support medical necessity may result in claim denial or inability to determine coverage during review.
- Lack of required history, physical exam, or diagnostic test results increases risk of denial or retrospective review.
Definitions
Background
Breast reduction (reduction mammaplasty) is a reconstructive surgical procedure performed to reduce breast size and relieve symptoms related to macromastia. UnitedHealthcare considers the procedure reconstructive and medically necessary in certain circumstances as defined by the InterQual CP: Procedures, Reduction Mammaplasty, Female criteria.
Revision History
Added Applicable Codes section; included instruction to refer to the Idaho Medicaid Provider Handbook for non‑covered and excluded services; added References to Supporting Information; archived previous version CS012ID.C.
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