CurrentUnitedHealthcarePolicy CSNC.MP.004.07

Breast Reduction Surgery (for North Carolina Only)

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This policy governs UnitedHealthcare Community Plan coverage review for breast reduction surgery in North Carolina. Medical necessity is determined under the North Carolina Medicaid Division of Health Benefits Clinical Coverage Policy, Physician 1A-12: Breast Surgeries, with supporting medical-record documentation required for review.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reduction Surgery (for North Carolina Only)

Policy CodePolicy CSNC.MP.004.07

Change TypeDocumentation updateno material clinical or coverage change

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionMaintain legible medical-record documentation supporting medical necessity, including relevant history, examination findings, and pertinent diagnostic results.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NCApplicable state

1Procedure codes listed

2Diagnosis codes listed

1A-12Governing clinical policy

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CurrentUnitedHealthcarePolicy CSNC.MP.004.07

Breast Reduction Surgery (for North Carolina Only)

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Policy Summary

PayerUnitedHealthcare

PolicyBreast Reduction Surgery (for North Carolina Only)

Policy CodePolicy CSNC.MP.004.07

Change TypeDocumentation updateno material clinical or coverage change

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionMaintain legible medical-record documentation supporting medical necessity, including relevant history, examination findings, and pertinent diagnostic results.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NCApplicable state

1Procedure codes listed

2Diagnosis codes listed

1A-12Governing clinical policy

North Carolina Medicaid Clinical Coverage Criteria

North Carolina Medicaid clinical coverage criteria

For medical-necessity clinical coverage criteria, refer to the North Carolina Medicaid Division of Health Benefits Clinical Coverage Policy, Physician, 1A-12: Breast Surgeries.

External governing criteria: Medical-necessity clinical coverage criteria are incorporated by reference to the North Carolina Medicaid Division of Health Benefits Clinical Coverage Policy, Physician, 1A-12: Breast Surgeries.

The breast reduction policy does not reproduce the external criteria.

Applicable Procedure and Diagnosis Codes

CPT CodesCPT

19318

Breast reduction

Diagnosis CodesICD-10

N62	Hypertrophy of breast
N65.1	Disproportion of reconstructed breast

Documentation Requirements

Documentation Required

Submit complete medical-necessity documentation

Maintain legible documentation in the patient's medical record that fully supports the medical necessity of the requested breast reduction surgery and addresses applicable benefit requirements. Make the records available upon request; documentation may be required to assess whether the member meets clinical coverage criteria but does not guarantee coverage.

Include relevant medical history.
Include physical examination findings.
Include results of pertinent diagnostic tests or procedures.
Maintain the documentation in the patient's medical record and make it available upon request.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reduction Surgery (for North Carolina Only)

Policy CodePolicy CSNC.MP.004.07

Change TypeDocumentation updateno material clinical or coverage change

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionMaintain legible medical-record documentation supporting medical necessity, including relevant history, examination findings, and pertinent diagnostic results.

SourceLink

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