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    • Trek Health
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    v1.0.28
    OpenPayerPolicy UpdatesPlastic/Reconstructive SurgeryUnitedHealthcare Breast Reduction Coverage Update …
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    CurrentUnitedHealthcarePolicy CS012TN.AA

    Breast Reduction Surgery (for Tennessee Only)

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    Policy governs coverage of breast reduction (reduction mammaplasty) for Medicaid and CoverKids members in Tennessee, outlining applicability, coding, documentation expectations, and reference to TennCare medical necessity criteria.

    Policy Summary
    PayerUnitedHealthcare
    PolicyBreast Reduction Surgery (for Tennessee Only)
    Policy CodePolicy CS012TN.AA
    Change TypeCoverage rationale and documentation language updated
    Effective DateAug 1, 2026
    Last ReviewAug 1, 2026
    Next Review Date
    Key ActionObtain and retain legible medical record documentation supporting medical necessity and submit prior authorization for CPT 19318 when required by Tennessee Medicaid/CoverKids rules.
    SourceLink
    POLICY UPDATE CHANGES

    Coverage Rationale updated to refer to the Tennessee Department of Finance and Administration, Bureau of TennCare § 1200-13-13-.10 for medical necessity clinical coverage criteria.

    Medical Records Documentation section added language specifying that benefit coverage is determined by federal, state, or contractual requirements and that medical records may be required to assess and support medical necessity.

    1CPT procedure code listed
    1ICD-10 diagnosis code listed
    Tennessee

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    State-specific applicability
    TennCare § 1200-13-13-.10Referenced clinical criteria source

    Coverage Criteria

    Medically Necessary (Reconstructive) Breast Reduction

    Covered when medical necessity criteria of TennCare § 1200-13-13-.10 are met.

    TennCare medical necessity: Member meets the medical necessity clinical coverage criteria as defined by the Tennessee Department of Finance and Administration, Bureau of TennCare § 1200-13-13-.10

    Policy defers to TennCare for specific clinical thresholds, exclusions, and applicability; refer to TennCare § 1200-13-13-.10 for details.

    Coverage for breast reduction surgery is subject to TennCare program exclusions and criteria. Specifically, medical necessity determinations and exclusions referenced in this policy defer to the Tennessee Department of Finance and Administration, Bureau of TennCare. See TennCare Medicaid, Chapter 1200-13-13-.10: Exclusions for the official list of services that may be excluded or that have specific coverage criteria.

    This policy does not itself list numeric thresholds to distinguish cosmetic-only from reconstructive breast reduction. Determinations between cosmetic and reconstructive procedures follow the TennCare medical necessity criteria referenced here. Providers should use the criteria in TennCare § 1200-13-13-.10 when documenting and requesting coverage for reduction mammaplasty.

    Coding

    Applicable CPT CodesCPT
    19318Reduction mammaplasty
    Applicable Diagnosis CodesICD-10
    N62Hypertrophy of breast

    Provider Actions and Requirements

    Prior Authorization

    Prior authorization required for CPT 19318 (TennCare/CoverKids)

    Prior authorization is required for CPT 19318 in accordance with Tennessee Medicaid/CoverKids program rules; use this UnitedHealthcare Medical Policy together with the Tennessee Department of Finance and Administration, Bureau of TennCare § 1200-13-13-.10 clinical coverage criteria when seeking authorization for reduction mammaplasty (CPT 19318).

    • CPT code: 19318 (Reduction mammaplasty).
    • Follow TennCare § 1200-13-13-.10 for specific medical necessity criteria that determine authorization.
    Note

    Provider action: Verify governing coverage rules before authorization

    Alert: When applying this policy, verify applicable federal, state, or contractual coverage requirements for the member; UnitedHealthcare’s Medical Policy is interpretive and coverage is governed by those requirements.

    • Check federal, state, or contractual requirements first — they govern in the event of a conflict.

    Background

    Breast reduction (reduction mammaplasty) is performed to reduce breast size and to alleviate symptoms related to macromastia or breast hypertrophy. This policy treats breast reduction as a potentially reconstructive and medically necessary procedure when the member meets the applicable TennCare clinical coverage criteria; specific clinical thresholds and indications are defined by TennCare § 1200-13-13-.10 rather than within this document.

    Definitions

    Hypertrophy — definition
    TermHypertrophy of breast
    DefinitionEnlargement of breast tissue (hypertrophy) as referenced in this policy
    ContextListed under Definitions for breast reduction (reduction mammaplasty) policy applicable to Tennessee Medicaid/CoverKids
    Related conditionMacromastia — clinical reason for reduction mammaplasty discussed in background
    Policy Summary
    PayerUnitedHealthcare
    PolicyBreast Reduction Surgery (for Tennessee Only)
    Policy CodePolicy CS012TN.AA
    Change TypeCoverage rationale and documentation language updated
    Effective DateAug 1, 2026
    Last ReviewAug 1, 2026
    Next Review Date
    Key ActionObtain and retain legible medical record documentation supporting medical necessity and submit prior authorization for CPT 19318 when required by Tennessee Medicaid/CoverKids rules.
    SourceLink
    On This Page
    Coverage CriteriaCodingProvider Actions and RequirementsBackgroundDefinitions
  1. UnitedHealthcare may use third‑party tools (e.g., InterQual) to assist in benefit administration; the policy does not constitute medical advice.
    2. Documentation Required

    Required documentation to support medical necessity

    Maintain complete, legible medical record documentation that supports medical necessity; records must be available upon request to support reviews and authorization decisions.

    • Relevant medical history.
    • Physical examination findings.
    • Results of pertinent diagnostic tests or procedures.
    • Documentation must be legible, retained in the patient’s medical record, and made available upon request.
    Denial Risk

    Denial triggers: insufficient documentation or nonconformance with governing requirements

    Claims or authorization requests may be denied if the medical record does not fully support medical necessity or if federal, state, or contractual coverage requirements are not met.

    • Insufficient or illegible documentation of history, exam, or diagnostic results can trigger denial.
    • Coverage conflicts with federal, state, or contractual requirements (including TennCare rules) can result in denial.