CurrentUnitedHealthcarePolicy CS012KY.10

Breast Reduction Surgery (for Kentucky Only)

This UnitedHealthcare Community Plan medical policy governs coverage and criteria for reduction mammaplasty (breast reduction) for Kentucky Medicaid members and applies to providers treating those members.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reduction Surgery (for Kentucky Only)

Policy CodePolicy CS012KY.10

Change TypeRevision (related policies and codes updated)

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionFollow InterQual CP criteria and applicable benefit requirements when requesting prior authorization for reduction mammaplasty.

SourceLink

POLICY UPDATE CHANGES

Related Policies and Applicable Codes updated; removed reference link to Panniculectomy and Body Contouring Procedures policy; archived previous policy version CS012KY.09.

Kentucky-onlystate applicability

InterQualprimary clinical criteria source

19318example procedure code

N62, N65.1example diagnosis codes

Coverage Criteria

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Medical necessity (InterQual-based)

Covered when InterQual CP criteria for reduction mammaplasty (female or adolescent) are met and applicable federal, state, or contractual benefit requirements allow coverage.

InterQual criteria requirement: Member meets InterQual CP: Reduction Mammaplasty, Female or Reduction Mammaplasty, Female (Adolescent) criteria.

Follow InterQual for specific clinical criteria and tests; if InterQual does not have applicable criteria, UnitedHealthcare may use other approved guidelines as permitted by state/contractual requirements.

Reduction mammaplasty related to gynecomastia is not covered under this policy. Providers should refer to the separate medical policy titled Gynecomastia Surgery (for Kentucky Only) for coverage determinations and criteria specific to gynecomastia-related breast reduction.

This policy does not enumerate specific conditions labeled as not medically necessary. Instead, determinations of medical necessity rely on the applicable InterQual criteria and the member’s federal, state, or contractual benefit plan requirements. Inclusion of codes in this policy is for reference only and does not by itself indicate coverage or guarantee payment.

Provider Actions & Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization is required for reduction mammaplasty when applicable under the member's benefit plan. Use InterQual® CP: Procedures (Reduction Mammaplasty, Female; Reduction Mammaplasty, Female (Adolescent)) as the primary clinical criteria to determine medical necessity.

Prior authorization checks must reference federal, state, and contractual benefit requirements.
In the absence of applicable InterQual criteria, UnitedHealthcare may apply UnitedHealthcare Medical Policies, Coverage Determination Guidelines, or Utilization Review Guidelines approved by the Kentucky Department for Medicaid Services.

Denial Risk

Coverage Disclaimer

Inclusion of a procedure or diagnosis code in this policy does not guarantee coverage or reimbursement. Coverage is determined by the member's federal, state, or contractual benefit requirements and applicable laws.

The list of codes provided in this policy is for reference only and may not be all-inclusive.
Other policies and guidelines may apply to coverage and billing determination.

Documentation Required

Documentation Requirements & Criteria Source

Documentation must support medical necessity per InterQual criteria and applicable benefit terms. Maintain and submit clinical records demonstrating that all required clinical criteria are met for the requested service.

Include relevant history, physical examination findings, symptom duration, conservative therapy attempts, and measurements if required by InterQual.
Retain copies of all submitted imaging, consult notes, and operative reports as requested during review.

Note

Instructions for Use

This Medical Policy provides interpretive guidance for UnitedHealthcare standard plans and is informational only; it does not constitute medical advice. Always verify applicable federal, state, or contractual requirements before making coverage decisions.

UnitedHealthcare reserves the right to modify Policies and Guidelines as necessary.
When conflicts exist, federal, state, or contractual requirements govern.

Definitions

Reduction mammaplasty definition (inv-11)

DefinitionReduction mammaplasty: surgical reduction of breast tissue; medical necessity is determined by InterQual CP criteria (Reduction Mammaplasty, Female and Reduction Mammaplasty, Female [Adolescent]).

Primary clinical criteria sourceInterQual CP: Reduction Mammaplasty, Female; Reduction Mammaplasty, Female (Adolescent).

Coverage stanceConsidered reconstructive and medically necessary in certain circumstances when InterQual criteria are met and applicable benefit requirements allow coverage.

Prior authorizationProviders should follow InterQual criteria and applicable benefit requirements for prior authorization decisions.

ScopeApplies to Kentucky Medicaid members per policy CS012KY.10.

Gynecomastia-related reduction — cross-reference (inv-12)

Related policyReduction mammaplasty related to gynecomastia is addressed under the separate policy 'Gynecomastia Surgery (for Kentucky Only)'.

Action for providersConsult the Gynecomastia Surgery (for Kentucky Only) policy for coverage determinations when breast reduction is related to gynecomastia.

Reference linkInterQual criteria link noted in policy for general reduction mammaplasty guidance; gynecomastia cases follow the separate policy guidance.

OpenPayer

Breast Reduction Surgery (for Kentucky Only)

Coverage Criteria

Coding

Provider Actions & Authorization

Background

Definitions

N62	Hypertrophy of breast
N65.1	Disproportion of reconstructed breast