CurrentUnitedHealthcarePolicy CSO12PAAA

Breast Reduction Surgery (for Pennsylvania Only)

Governs coverage and medical necessity determination for reduction mammaplasty (breast reduction) for UnitedHealthcare members in Pennsylvania; references InterQual criteria for clinical decision-making.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reduction Surgery (for Pennsylvania Only)

Policy CodePolicy CSO12PAAA

Change TypeRelated policies and codes updatedminor reference removals

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization using InterQual Reduction Mammaplasty criteria when requesting coverage for CPT 19318.

SourceLink

POLICY UPDATE CHANGES

Removed reference/link to the Medical Policy titled Panniculectomy and Body Contouring Procedures (for Pennsylvania Only).

Related Policies and Applicable Codes updated.

Pennsylvania-onlystate applicability

InterQualclinical criteria source

19318example procedure code

N62, N65.1example diagnosis codes

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Medical Necessity (InterQual)

Covered when the InterQual criteria for reduction mammaplasty are met.

InterQual-based medical necessity: Patient meets the InterQual CP criteria for Reduction Mammaplasty (Female) or Reduction Mammaplasty (Female, Adolescent)use InterQual tool

The policy delegates detailed clinical criteria to the InterQual CP sets; use the InterQual decision support tool to determine whether detailed clinical criteria are met.

Reduction mammaplasty procedures that are related to gynecomastia are not covered under this UnitedHealthcare Pennsylvania policy. For cases of gynecomastia, refer to the separate policy titled Gynecomastia Surgery (for Pennsylvania Only) for coverage and prior authorization guidance.

Breast reduction (reduction mammaplasty) is considered reconstructive and medically necessary when the InterQual clinical criteria are met. Services that do not meet the referenced InterQual criteria or are not supported by the applicable coding/clinical documentation may be determined not medically necessary and may be denied on a case-by-case basis.

Applicable Procedure and Diagnosis Codes

Covered/Referenced CPT CodesCPT

19318

Reduction mammaplasty (CPT listed in Applicable Codes)

Referenced ICD-10 CodesICD-10

N62	Hypertrophy of breast
N65.1	Disproportion of reconstructed breast

None specified

Thresholds/valuesNone specified

Source sectionApplicable Codes — no numerical thresholds or clinical thresholds listed

ImplicationPolicy does not define numeric measurement thresholds (e.g., tissue weight, symptom duration) for reduction mammaplasty; clinical criteria are delegated to InterQual

Provider Responsibilities and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization/adjudication for reduction mammaplasty should follow InterQual clinical policy (CP) criteria. Use the InterQual CP: Procedures for Reduction Mammaplasty (Female, Adolescent and Female) when submitting requests; UnitedHealthcare may rely on these criteria to determine medical necessity.

Denial Risk

Nonconforming Requests May Be Denied

Requests that do not meet the Pennsylvania-specific addendum and/or InterQual criteria may be denied. The policy applies only to Pennsylvania; requests that fall outside the PARP criteria will be evaluated on a case-by-case basis and may be subject to denial if nonconforming.

Pennsylvania Addendum / PARP requirements
InterQual CP criteria for reduction mammaplasty

Documentation Required

Coding on Documentation

Include applicable procedure and diagnosis codes on all documentation and claims to support medical necessity determinations and proper adjudication. Codes listed in the policy are for reference and do not guarantee coverage or payment.

Procedure: CPT 19318
Diagnoses: ICD-10 N62 (Hypertrophy of breast); N65.1 (Disproportion of reconstructed breast)
Reminder: Inclusion of codes is for reference only and does not guarantee reimbursement

Step Therapy

No Specified Step Therapy

No specific step-therapy sequence is specified in this policy. UnitedHealthcare may use InterQual or other third-party tools to assist in utilization management, but there is no mandatory step-therapy order defined here.

No explicit step-therapy sequence required
InterQual or other utilization management tools may be applied

Background

Reduction mammaplasty (breast reduction) is considered reconstructive and medically necessary in certain circumstances under this Pennsylvania-specific policy. Clinical medical necessity determinations use the InterQual CP: Reduction Mammaplasty (Female) and Reduction Mammaplasty (Female, Adolescent) criteria sets as the authoritative source for prior authorization and adjudication.

Definitions and Clinical Criteria Sources

InterQual CP: Reduction Mammaplasty

InterQual criteria sets referencedInterQual CP: Reduction Mammaplasty, Female; InterQual CP: Reduction Mammaplasty, Female, Adolescent

RoleThese InterQual procedure criteria are the clinical decision source used to determine medical necessity for reduction mammaplasty under this policy

Exclusion noteReduction related to gynecomastia is not covered under this policy; see Gynecomastia Surgery (for Pennsylvania Only)

Provider actionPrior authorization/adjudication should follow the referenced InterQual CP sets when determining medical necessity for CPT 19318