CurrentUnitedHealthcarePolicy CSNC.MP.004.06

Breast Surgery (North Carolina) — Clinical Coverage Guidance

Governs UnitedHealthcare coverage guidance for breast surgeries in North Carolina and directs readers to the North Carolina Medicaid Clinical Coverage Policy for medical necessity criteria.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Surgery (North Carolina) — Clinical Coverage Guidance

Policy CodePolicy CSNC.MP.004.06

Change TypeRoutine reviewno coverage changes

Effective DateJun 1, 2025

Next Review Date

Key ActionVerify federal, state, or contractual benefit requirements and prior authorization applicability before submitting claims.

SourceLink

POLICY UPDATE CHANGES

Routine review; no change to coverage guidelines

1Applicable state

3Referenced codes listed

1External policy referenced

3Related UHC policies

Coverage Criteria

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.

The presence of a procedure or diagnosis code in this policy is for reference only. Listing of a code does not imply that the service described by the code is a covered or non‑covered health service, nor does it guarantee payment. Benefit coverage is determined by applicable federal, state, or contractual requirements and laws; other policies and guidelines may apply.

Provider Actions and Billing Guidance

Prior Authorization

Prior authorization / check benefit terms

Providers should verify whether prior authorization or other utilization management requirements apply before providing services. Check federal, state, or contractual benefit plan requirements and member-specific eligibility and benefits for prior authorization applicability; if required, obtain authorization per UnitedHealthcare procedures before scheduling services.

Verify prior authorization when required by the member's benefit plan or state/federal mandate.
Confirm member eligibility and benefit terms before rendering services.
Obtain authorization through UnitedHealthcare if the plan requires prior approval.

Note

Verify governing benefit terms

Before delivering care, confirm applicable contractual, state, and federal requirements that may affect coverage or payment. If plan documents or law conflict with this policy, those governing terms control decisions about coverage and payment.

Review the member's contract and summary plan description for any deviations from this policy.
When state or federal law mandates coverage that differs from this policy, follow the law.

Denial Risk

Code listing is not a coverage guarantee

Inclusion of a code or diagnosis in this policy is for reference only and does not guarantee coverage or payment. Coverage determinations are based on the member's benefit plan, applicable laws, and medical necessity as documented in the medical record.

Listing a procedure or diagnosis code here does not imply the service is covered.
Benefit coverage and reimbursement are determined by the member's federal, state, or contractual benefit terms and applicable laws.

Note

Instructions for use

This policy is intended to assist in interpreting UnitedHealthcare standard benefit plans and is informational only. Before using this policy, check federal, state, or contractual benefit plan requirements; in the event of a conflict, those requirements govern. UnitedHealthcare may use third-party tools (for example, InterQual) to help administer benefits. This policy does not constitute medical advice and does not replace the independent professional judgment of the treating provider.

Check member-specific benefit plan documents and applicable laws before applying this policy.
UnitedHealthcare reserves the right to modify Policies and Guidelines as necessary.
Third-party tools may be used to assist in coverage determinations.

Background

This UnitedHealthcare policy for North Carolina directs readers to the North Carolina Medicaid Clinical Coverage Policy (Physician: 1A‑12) for the detailed medical necessity clinical coverage criteria for breast surgeries. The policy is intended as interpretive assistance for standard UnitedHealthcare benefit plans; when federal, state, or contractual benefit terms conflict with this document, those governing requirements prevail.

Definitions / Key Codes

Breast reduction (19318)

CPT code19318 — Breast reduction

Code systemCPT

Reference noteListed in Applicable Codes; inclusion does not guarantee coverage or payment

N62

ICD-10 codeN62 — Hypertrophy of breast

Code systemICD-10

Reference noteListed in Applicable Codes; inclusion does not guarantee coverage or payment

N65.1

ICD-10 codeN65.1 — Disproportion of reconstructed breast

Code systemICD-10

Reference noteListed in Applicable Codes; inclusion does not guarantee coverage or payment

Policy Summary

PayerUnitedHealthcare

PolicyBreast Surgery (North Carolina) — Clinical Coverage Guidance

Policy CodePolicy CSNC.MP.004.06

Change TypeRoutine reviewno coverage changes

Effective DateJun 1, 2025

Next Review Date

Key ActionVerify federal, state, or contractual benefit requirements and prior authorization applicability before submitting claims.

SourceLink

On This Page

OpenPayer

Breast Surgery (North Carolina) — Clinical Coverage Guidance

Coverage Criteria

Applicable Codes

Provider Actions and Billing Guidance

Background

Definitions / Key Codes

Revision History

N62	Hypertrophy of breast
N65.1	Disproportion of reconstructed breast