CurrentUnitedHealthcarePolicy CS012NJ.U

Breast Reduction Surgery (for New Jersey Only)

This policy governs medical necessity and coverage considerations for breast reduction surgery (reduction mammaplasty) for UnitedHealthcare members in New Jersey. It affects providers seeking authorization or coverage determination for female and adolescent reduction mammaplasty.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reduction Surgery (for New Jersey Only)

Policy CodePolicy CS012NJ.U

Change TypeRevised — related policies and code references updated

Effective DateJune 1, 2025

Next Review Date

Key ActionFollow InterQual CP criteria for Reduction Mammaplasty when requesting authorization for female or adolescent patients.

SourceLink

POLICY UPDATE CHANGES

Related Policies and Applicable Codes were updated; reference link to Panniculectomy and Body Contouring Procedures (for New Jersey Only) was removed.

New Jerseyapplicability (state)

InterQualclinical criteria source referenced

19318example procedure code listed

N62, N65.1example diagnosis codes listed

Coverage Criteria

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Medically necessary when InterQual criteria are satisfied

Covered when InterQual CP criteria for Reduction Mammaplasty are met.

InterQual-based criteria: Reduction mammaplasty (female or adolescent) meets InterQual CP clinical criteria for medical necessitysee InterQual CP: Reduction Mammaplasty, Female; Reduction Mammaplasty, Female, Adolescent

Refer to InterQual for the exact clinical elements and measurements

Reduction mammaplasty procedures performed for gynecomastia-related indications are not evaluated under this policy. For those cases, providers should refer to the separate Gynecomastia Surgery (for New Jersey Only) medical policy for coverage and medical necessity guidance.

This policy does not itself enumerate an exhaustive list of conditions that are "not medically necessary." Listing a code here does not imply that the service is covered; benefit coverage is determined by the member's federal, state, or contractual plan terms and applicable law. Providers must check the governing benefit plan when determining coverage and reimbursement.

Coding

CPT Codes (listed)CPT

19318

Breast reduction

ICD-10 Codes (listed)ICD-10

N62	Hypertrophy of breast
N65.1	Disproportion of reconstructed breast

No numeric thresholds in policy

Numeric thresholdsNone specified — policy defers to InterQual clinical criteria rather than listing numeric thresholds.

Threshold sourceInterQual CP: Reduction Mammaplasty, Female; Reduction Mammaplasty, Female, Adolescent (see policy links).

Implication for coding/authorizationNo weight/BMI/breast volume or resection-mass numeric values are listed in this policy; use InterQual criteria when assessing medical necessity.

DocumentationProviders should follow InterQual elements for clinical measurements and document per those criteria for authorization.

Provider Actions & Authorization

Prior Authorization

Prior Authorization Required

Prior authorization and review for medical necessity use InterQual® CP criteria for Reduction Mammaplasty (Female and Adolescent). Refer to the InterQual criteria when submitting requests.

InterQual CP criteria required for prior authorization and medical necessity determinations
Click here to view the InterQual® criteria

Note

Check Governing Benefit Terms

The provider must verify governing benefit terms before relying on this policy. This Medical Policy interprets UnitedHealthcare standard benefit plans; federal, state, or contractual benefit plan terms control and prevail in case of conflict.

Providers must check the member's specific federal, state, or contractual benefit terms
This policy is interpretive and does not replace the plan's governing documents

Denial Risk

Coverage Depends on Benefit Plan

Inclusion of a procedure or diagnosis code in this policy is for reference only and does not guarantee coverage or payment. Coverage depends on the member's benefit plan and applicable laws; the presence of a code does not imply a right to reimbursement.

Coverage depends on the member's specific benefit plan and applicable legal requirements
Listing of a code does not guarantee coverage or payment

Background

Breast reduction (reduction mammaplasty) is a reconstructive surgical procedure performed to reduce breast size and relieve symptoms associated with macromastia. UnitedHealthcare considers reduction mammaplasty medically necessary when the applicable InterQual CP criteria for Reduction Mammaplasty (Female or Adolescent) are satisfied. Clinical determinations rely on the InterQual criteria rather than numeric thresholds listed in this policy. Relevant procedure and diagnosis codes are provided for reference (for example, CPT 19318 and ICD-10 codes such as N62), but the presence of a code does not guarantee coverage; authorization and coverage must follow InterQual when applicable and conform to the member's benefit plan.

Definitions

Definition: Reduction mammaplasty

TermReduction mammaplasty (breast reduction) — surgical procedure to reduce breast size as referenced by InterQual clinical criteria for female and adolescent patients.

Clinical criteria sourceInterQual CP: Reduction Mammaplasty, Female; Reduction Mammaplasty, Female, Adolescent — policy requires these InterQual criteria for medical necessity determinations.

ScopeApplies to female and adolescent reduction mammaplasty; gynecomastia-related reduction is covered under a separate Gynecomastia Surgery policy (New Jersey only).

Policy stanceProcedure is considered reconstructive and medically necessary when InterQual clinical coverage criteria are met.