CurrentUnitedHealthcarePolicy CS012KS.02

Breast Reduction Surgery (for Kansas Only)

This policy governs coverage for breast reduction (reduction mammaplasty) for UnitedHealthcare members in Kansas and cites InterQual criteria for medical necessity. It affects Kansas-based providers and members whose benefits reference UnitedHealthcare medical policies.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reduction Surgery (for Kansas Only)

Policy CodePolicy CS012KS.02

Change TypeRevised

Effective DateJul 1, 2025

Next Review Date

Key ActionObtain prior authorization using InterQual CP criteria and submit the documentation required by InterQual and contractual benefit terms.

SourceLink

POLICY UPDATE CHANGES

Related Policies and Applicable Codes were updated; removed a reference link to the Panniculectomy and Body Contouring Procedures policy and archived the previous policy version CS012KS.01.

CPT 19318procedure code listed for breast reduction

InterQualexternal clinical criteria referenced for medical necessity

Kansasapplicability by state

Archivedpolicy history action

Coverage Criteria

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reduction Surgery (for Kansas Only)

Policy CodePolicy CS012KS.02

Change TypeRevised

Effective DateJul 1, 2025

Next Review Date

Key ActionObtain prior authorization using InterQual CP criteria and submit the documentation required by InterQual and contractual benefit terms.

SourceLink

On This Page

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Medical necessity (InterQual-referenced)

Covered when ALL of the following are met per InterQual criteria

InterQual-based criteria: Medical necessity for reduction mammaplasty is determined using InterQual CP: Reduction Mammaplasty, Female and Reduction Mammaplasty, Female, Adolescent.See InterQual

Providers must meet the detailed clinical criteria in InterQual for authorization; this policy defers to InterQual for the specific clinical triggers.

Reduction mammaplasty related to gynecomastia is not covered under this policy. Providers should refer to the separate policy titled Gynecomastia Surgery (for Kansas Only) for coverage rules and requirements applicable to gynecomastia-related procedures.

The list of procedure and diagnosis codes included in this policy is provided for reference only. Listing a code does not imply the service described is covered or not covered. Benefit coverage is determined by federal, state, or contractual requirements and applicable law; inclusion of a code does not guarantee reimbursement or payment. Services that do not meet the referenced InterQual criteria or applicable contractual benefit terms would be considered not medically necessary.

Applicable Codes

Applicable CPT CodesCPTCovered

19318

Breast reduction

Applicable ICD-10 Codes (examples listed)ICD-10

N62	Hypertrophy of breast
N65.1	Disproportion of reconstructed breast

Breast reduction (CPT 19318) — Reduction mammaplasty

Procedure codeCPT 19318

Procedure descriptionBreast reduction (Reduction mammaplasty)

Coding noteListing of a code in this policy does not imply the service described by the code is a covered or non-covered health service; benefit coverage is determined by federal, state, or contractual requirements.

Related policiesRefer to Breast Reconstruction; Cosmetic and Reconstructive Procedures; Gender Dysphoria Treatment; Gynecomastia Surgery (Kansas only).

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization decisions for reduction mammaplasty are made using InterQual® CP criteria (Reduction Mammaplasty, Female and Reduction Mammaplasty, Female, Adolescent). Providers should obtain prior authorization when required by the member's plan.

InterQual criteria are the primary clinical criteria used for prior authorization decisions.
Prior authorization requirements vary by plan; verify benefit plan prior authorization rules before scheduling.

Documentation Required

Benefit Documentation Guidance

This Medical Policy is interpretive and supplemental to federal, state, and contractual benefit terms. Providers must reference the applicable federal, state, or contractual benefit requirements to determine coverage for a specific member. In the event of a conflict between this policy and federal, state, or contractual benefit terms, the federal, state, or contractual requirements govern. UnitedHealthcare uses InterQual® criteria as the primary medical/surgical criteria; if InterQual® does not have applicable criteria, UnitedHealthcare may use other approved UnitedHealthcare Medical Policies.

Check the member’s specific benefit plan and any applicable state or federal mandates before relying on this policy.
This policy is informational and does not constitute medical advice.

Denial Risk

Denial Triggers

Services that do not meet the referenced InterQual criteria for reduction mammaplasty may be denied. Inclusion of a code in this policy does not guarantee coverage or payment.

Claims for procedures that fail to meet InterQual medical necessity criteria are subject to denial.
Coding lists are for reference and are not exhaustive; verify coding and applicability to the member’s benefits.

Background

Breast reduction (reduction mammaplasty) is considered reconstructive and may be medically necessary in certain circumstances when the detailed clinical criteria are met. UnitedHealthcare uses InterQual CP criteria (Reduction Mammaplasty, Female and Reduction Mammaplasty, Female, Adolescent) to determine medical necessity for authorization; providers must meet the InterQual clinical triggers and submit the documentation required by InterQual and contractual benefit terms.

OpenPayer

Breast Reduction Surgery (for Kansas Only)

Coverage Criteria

Applicable Codes

Provider Actions and Requirements

Background

Definitions