CurrentUnitedHealthcarePolicy CS012TN.Z

Breast Reduction Surgery (for Tennessee Only)

This policy governs coverage and medical necessity determinations for breast reduction (reduction mammaplasty) for Tennessee Medicaid and CoverKids members under UnitedHealthcare, referencing TennCare rules.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reduction Surgery (for Tennessee Only)

Policy CodePolicy CS012TN.Z

Change TypeRevised (applicable codes updatedprior version archived)

Effective DateJul 1, 2025

Next Review Date

Key ActionObtain prior authorization and follow the policy and TennCare clinical criteria when requesting coverage for breast reduction (CPT 19318).

SourceLink

POLICY UPDATE CHANGES

Applicable Codes list was updated and a previous policy version was archived.

Related Policies and Applicable Codes entries were modified in the policy history.

Tennessee-onlystate applicability

Medicaid & CoverKidsaffected programs

19318example procedure code

N62, N65.1example diagnosis codes

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Medical necessity (governing regulation)

Covered when consistent with TennCare Medicaid rules and medical necessity determination.

Governing rule: Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances as defined by TennCare Medicaid Chapter 1200-13-13-.10.

Refer to TennCare rule for detailed clinical criteria.

The list of procedure and diagnosis codes in this policy is provided for reference only. Listing a code does not imply that the service described by the code is a covered health service; benefit coverage and claim payment are determined by applicable federal, state, or contractual requirements and laws governing the member’s plan.

This policy does not by itself enumerate specific services that are ‘not medically necessary.’ Determinations about medical necessity or non‑coverage depend on federal, state, and contractual requirements (for Tennessee members, TennCare rules may apply) and on the member’s benefit plan and applicable laws.

Prior Authorization, Documentation, and Coverage Determination Guidance

Prior Authorization

Prior authorization and clinical criteria

Coverage decisions and claim payment must follow the applicable federal, state, and contractual benefit requirements. Providers should verify member benefits and any TennCare or other state-specific rules that may apply before rendering services.

Check member-specific benefits and any state/TennCare rules prior to authorization or treatment.
If federal, state, or contractual requirements conflict with this policy, those requirements govern.

Note

Provider guidance

This policy is informational and is not a substitute for clinical judgment. UnitedHealthcare may use third-party tools (for example, InterQual®) to assist in benefit administration. Before relying on this policy, confirm applicable benefit terms and any plan-specific requirements.

Documentation Required

Coverage decision sources and documentation

Providers must reference federal, state, or contractual benefit requirements when determining coverage. Document clinical indications, member benefit verification, and any prior authorization references in the medical record to support medical necessity and facilitate claims processing.

Document clinical rationale and supporting records in the member’s chart.
Include prior authorization numbers and dates on claims when applicable.
Retain documentation showing benefit verification and any applicable state rules (e.g., TennCare) that influenced the coverage decision.

Billing Rule

Coding inclusion is not coverage guarantee

Listing of a code in this policy does not imply that the service described by the code is a covered or non‑covered health service. Inclusion of a code does not guarantee reimbursement or claim payment. Always confirm coverage and authorization requirements for the member’s specific plan.

Code listings are for reference only and are not a guarantee of coverage.
Validate coverage and billing rules with the member’s benefit plan before submitting claims.

Clinical Background

Breast reduction (reduction mammaplasty) is addressed in this policy as a reconstructive procedure that may be medically necessary in certain circumstances. Coverage and medical necessity determinations reference applicable TennCare regulations and the member’s benefit contract; the procedure is represented in the Applicable Codes list by CPT 19318 (breast reduction), with related diagnoses such as N62 (hypertrophy of breast) and N65.1 (disproportion of reconstructed breast) shown for reference.

Key Definitions and Code References

Breast reduction (CPT 19318) — CPT code reference

CPT code19318 - Breast reduction (Breast reduction; CPT® 19318)

Coding systemCPT (American Medical Association)

Usage noteCode is listed for reference only; listing does not guarantee coverage or payment.

Relevant diagnosis codes

N62Hypertrophy of breast

N65.1Disproportion of reconstructed breast

Listing caveatDiagnosis codes are provided for reference only; inclusion does not imply coverage or payment guarantee.