CurrentUnitedHealthcarePolicy CS012.AB

Breast Reduction Surgery (Reduction Mammaplasty) Coverage Criteria

Defines UnitedHealthcare coverage stance for reduction mammaplasty (female and adolescent) and directs use of InterQual criteria to determine medical necessity; excludes certain state-specific versions. Affects providers requesting coverage for breast reduction for UnitedHealthcare members.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reduction Surgery (Reduction Mammaplasty) Coverage Criteria

Policy CodePolicy CS012.AB

Change TypeState applicability and documentation clarifications

Effective DateJun 1, 2025

Next Review Date

Key ActionFollow InterQual CP: Reduction Mammaplasty for prior authorization and medical necessity determinations.

SourceLink

POLICY UPDATE CHANGES

Added language to indicate this Medical Policy does not apply to the state of Nebraska; refer to the state-specific policy version.

Removed content/language pertaining to the state of Mississippi.

Added language to indicate this Medical Policy does not apply to the states of Idaho and Kansas; refer to the state-specific policy versions.

Updated Medical Records Documentation language clarifying that documentation may be required to assess clinical criteria but does not guarantee coverage.

InterQualexternal criteria referenced for medical necessity

2 CPT/ICD groupsexample codes listed (CPT/ICD groups)

Multiplestates with separate state-specific policies

Related Billing Codes

CPT-19318-BREAST-REDUCTION-SURGERY

CPT 19318: Breast Reduction Surgery

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.

Coverage Criteria

Medical Necessity (delegated to InterQual)

Covered when ALL of the following are met per InterQual criteria:

InterQual-based medical necessity: Member meets the InterQual CP criteria for Reduction Mammaplasty (Female or Adolescent)See InterQual

UnitedHealthcare uses InterQual CP: Reduction Mammaplasty (Female) and Reduction Mammaplasty (Female, Adolescent) to determine medical necessity; specific objective measurements and symptom requirements are detailed in InterQual.

This Medical Policy does not apply to certain states. Refer to the state-specific breast reduction policy or guideline for members in the following jurisdictions: Idaho, Indiana, Kansas, Kentucky, Louisiana, Nebraska, New Jersey, New Mexico, North Carolina, Ohio, Pennsylvania, and Tennessee. The policy history includes recent updates adding Nebraska, Idaho, and Kansas to the list of states with separate state-specific policy versions; always confirm the applicable state policy before requesting coverage.

Procedures that do not meet the InterQual CP criteria for Reduction Mammaplasty (Female or Adolescent) are not considered medically necessary under this UnitedHealthcare policy. UnitedHealthcare delegates medical necessity determinations for reduction mammaplasty to the specified InterQual clinical practice (CP) criteria and requires that all InterQual conditions be met for coverage.

Coding (Reference Only)

Applicable CPT Codes (reference only)CPT

19318

Breast reduction.

Applicable Diagnosis Codes (reference only)ICD-10

N62	Hypertrophy of breast.
N65.1	Disproportion of reconstructed breast.

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization/medical necessity determinations should follow InterQual® CP: Reduction Mammaplasty (female and adolescent). Click here to view the InterQual® criteria.

InterQual CP: Reduction Mammaplasty, Female
InterQual CP: Reduction Mammaplasty, Female, Adolescent

Note

Documentation Required

Medical Records Documentation

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee that the service will be covered. Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws; these requirements govern in the event of a conflict.

Background

Breast reduction (reduction mammaplasty) is performed to relieve symptoms related to breast hypertrophy or disproportion and is considered a reconstructive procedure when clinical criteria are met. UnitedHealthcare uses InterQual CP: Reduction Mammaplasty (Female and Adolescent) to determine medical necessity; specific objective measurements and symptom requirements are defined within the InterQual criteria. Providers requesting prior authorization should follow the InterQual guidance when submitting requests for reduction mammaplasty.

Definitions / Example Codes

Applicable CPT (example)

CPT code19318 — Breast reduction

Code systemCPT

Usage noteListed for reference only; inclusion does not guarantee coverage or payment

Applicable Diagnosis Codes (examples)

ICD-10 codeN62 — Hypertrophy of breast

Related diagnosisN65.1 — Disproportion of reconstructed breast

Usage noteDiagnosis codes provided for reference only; listing does not imply coverage