Loading...
Defines UnitedHealthcare Community Plan of Indiana coverage positions for reconstructive breast surgery and related procedures, including indications post-mastectomy, congenital anomalies, implant removal for Allergan BIOCELL textured implants, related adjunct procedures (nipple/areola creation, ADM use, tissue expanders), lymphedema treatments, and exclusions for cosmetic indications.
Added language clarifying medical records documentation requirements for reviews (including that documentation may be required, must fully support medical necessity, and be made available upon request).
Removed CPT code 19380 from the Applicable Codes section.
Updated Supporting Information sections: Clinical Evidence, FDA, and References to reflect current information.
Scope: UnitedHealthcare Community Plan of Indiana medical policy CS011IN.10 (effective February 1, 2026) applies only to members in Indiana and references InterQual clinical criteria for detailed medical necessity determinations. The policy takes a mixed coverage stance: reconstructive breast procedures and certain related therapies are covered when criteria are met, while cosmetic indications are excluded.
Summary of coverage: The policy covers breast reconstruction during or after mastectomy and for treatment of congenital disorders or severe breast disfigurement, including associated adjunct procedures (e.g., nipple/areola creation/tattooing, mastopexy when required prior to mastectomy, implant-based reconstruction with tissue expanders) and use of Acellular Dermal Matrix (ADM) when part of reconstructive surgery. It also covers management of post-mastectomy complications such as lymphedema treatments (complex decongestive physiotherapy, lymphedema pumps, compression sleeves, elastic bandages) and implant removal for individuals with Allergan BIOCELL textured implants. The policy excludes procedures performed for purely cosmetic indications (e.g., breast enhancement, mastopexy not related to mastectomy, liposuction, correction of asymmetry not related to mastectomy/congenital disorder).
Medically necessary reconstructive breast surgery
Covered when ALL of the following are met:
ALL of the following
Procedures considered reconstructive when performed with breast reconstruction
The following procedures may be considered reconstructive and medically necessary when performed with a breast reconstructive procedure:
ANY of the following
ADM defined in policy definitions and FDA advisory referenced
Treatment of complications post-mastectomy (covered)
Covered and medically necessary for the following complications:
ANY of the following
Removal of breast implants (covered)
Removal is considered reconstructive and medically necessary when ANY of the following are met:
ANY of the following
Referenced InterQual criteria for specifics
Nipple repair/reconstruction for inverted nipples (covered)
Covered when ONE of the following are met:
ANY of the following
Cosmetic / Not medically necessary
Not covered when ALL of the following apply (i.e., cosmetic):
Examples of cosmetic/excluded indications (not related to mastectomy)
Medical Records Documentation Used for Reviews
Added language specifying documentation expectations:
| 11920 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, <=6.0 sq cm |
| 11921 | Tattooing, intradermal introduction of insoluble opaque pigments; 6.1 to 20.0 sq cm |
| 11922 | Tattooing, intradermal; each additional 20.0 sq cm |
| 11970 | Replacement of tissue expander with permanent implant |
| 11971 | Removal of tissue expander without insertion of implant |
| 15271 | Application of skin substitute graft to trunk, arms, legs; total wound surface area up to 100 sq cm; first 25 sq cm or less |
| 15272 | Application of skin substitute graft; each additional 25 sq cm |
| 15771 | Grafting of autologous fat by liposuction; 50 cc or less injectate |
| 15772 | Grafting of autologous fat; each additional 50 cc injectate |
| 15777 | Implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement |
| L8600 | Implantable breast prosthesis, silicone or equal |
| S2066 | Breast reconstruction with gluteal artery perforator (GAP) flap, unilateral |
| S2067 | Breast reconstruction with 'stacked' DIEP/GAP flap(s), unilateral |
| S2068 | Breast reconstruction with DIEP or SIEA flap, unilateral |
| S8950 | Complex lymphedema therapy, each 15 minutes |
| C50.011 | Malignant neoplasm of nipple and areola, right female breast |
| C50.012 | Malignant neoplasm of nipple and areola, left female breast |
| C50.019 | Malignant neoplasm of nipple and areola, unspecified female breast |
| C50.021 | Malignant neoplasm of nipple and areola, right male breast |
| C50.022 | Malignant neoplasm of nipple and areola, left male breast |
| C50.029 | Malignant neoplasm of nipple and areola, unspecified male breast |
| C50.111 | Malignant neoplasm of central portion of right female breast |
| C50.112 | Malignant neoplasm of central portion of left female breast |
| C50.119 | Malignant neoplasm of central portion of unspecified female breast |
| C50.121 | Malignant neoplasm of central portion of right male breast |
| 11920 | See main CPT list (asterisk indicates not managed for medical necessity review in Indiana at effective date) |
| 11970 | Replacement of tissue expander with permanent implant (asterisked) |
| 11971 | Removal of tissue expander without insertion of implant (asterisked) |
| 15271 | Application of skin substitute graft (asterisked) |
| 15272 | Application of skin substitute graft additional (asterisked) |
| 15771 | Autologous fat grafting <=50 cc (asterisked) |
| 15772 | Autologous fat grafting additional 50 cc (asterisked) |
| 15777 | Implantation of biologic implant (ADM) (asterisked) |
| 19328 | Removal of intact breast implant (asterisked) |
| 19330 | Removal of ruptured breast implant (asterisked) |
| 19380 | Removed from applicable codes for this policy (no longer listed as applicable) |
Document medical necessity in medical record
The patient's medical record must contain documentation that fully supports medical necessity; include relevant history, physical exam findings, and results of pertinent diagnostic tests or procedures. Ensure records are legible and maintained so they can be produced if requested for review.
Prior authorization / InterQual criteria required
InterQual clinical coverage criteria (InterQual CP: Procedures, Breast Reconstruction and InterQual CP: Procedures, Breast Implant Removal) are referenced for medical necessity determinations. Providers should verify the payer's prior authorization and notification requirements for Indiana before scheduling or performing services.
Some CPT/HCPCS codes not managed for medical necessity review
Codes marked with an asterisk in the policy are not managed for medical necessity review for the state of Indiana as of the policy effective date; providers must consult the current payer prior authorization list to confirm which codes require review.
Intraoperative perfusion assessment not separately reimbursable
Intraoperative assessment of vascular perfusion is considered an integral part of breast reconstruction and is not separately reimbursable under this policy.
Code removal impact
CPT code 19380 has been removed from the applicable codes list and should not be billed under this policy effective February 1, 2026; verify any federal, state, or contractual requirements which may differ or govern reimbursement.
State-specific applicability
This policy applies only to members in the state of Indiana; providers must refer to applicable federal, state, or contractual requirements for coverage rules that may supersede this policy.
Maintain medical record documentation supporting medical necessity
Maintain legible medical record documentation that fully supports the medical necessity for requested services; documentation may be requested for review but its presence does not guarantee coverage.
Reference governing authorities for coverage decisions
When determining coverage and payment, consult federal, state, and contractual requirements because they may override the standard benefit policy.
Background: Reconstructive breast surgery may be required after lumpectomy or mastectomy for breast cancer or to restore anatomy after congenital conditions (e.g., Poland syndrome), radiation, trauma, or severe disfigurement; reconstruction can be immediate or delayed. The policy references InterQual clinical criteria (InterQual CP: Procedures, Breast Reconstruction and Breast Implant Removal) for medical necessity determinations and notes that federal, state, or contractual requirements may affect coverage.
Associated procedures and treatments: When performed with reconstructive breast surgery, covered adjuncts include creation of the nipple and areola (including tattooing), mastopexy or reduction when needed to preserve nipple viability prior to mastectomy, implant-based reconstruction with tissue expanders, and use of ADM. Post-mastectomy complications covered include lymphedema care (complex decongestive therapy, pumps, compression sleeves, bandages) and treatment of post-operative infections. Implant removal is considered reconstructive and medically necessary for individuals implanted with Allergan BIOCELL textured implants, with or without capsulectomy/capsulotomy as indicated.
Regulatory context: The policy cites FDA communications relevant to implants, tissue expanders, and ADM products — including the 2019 Allergan BIOCELL textured implant recall and FDA advisories about ADM products and breast implant safety — and clarifies that implants, expanders, and ADMs require FDA approval while reconstruction procedures themselves are surgical and not FDA-regulated as devices.
Documentation expectations: The policy adds required medical records documentation language specifying that the patient’s record must fully support medical necessity (relevant history, physical exam, and diagnostic test results), be legible, maintained in the record, and be made available upon request for reviews.
Definitions: Acellular Dermal Matrix (ADM) — a type of surgical mesh developed from human or animal skin in which the cells are removed leaving the support structure (FDA 2021).
Anaplastic Lymphoma — a rare T‑cell non‑Hodgkin lymphoma; breast implant–associated ALCL most commonly presents as a delayed fluid collection around a textured implant or as a mass in the fibrous capsule surrounding the implant.
Congenital Anomaly — a physical developmental defect present at birth and identified within the first twelve months of life.
Mastectomy — surgery to remove all or part of the breast; types vary by amount of tissue and lymph nodes removed.
Mastopexy/Breast Lift — a procedure that raises the breast, removes excess skin, and tightens surrounding tissue.
Added documentation requirements: language clarifying that benefit coverage is determined by federal, state, or contractual requirements; medical records documentation may be required to assess clinical criteria but does not guarantee coverage; the patient's medical record must contain documentation that fully supports medical necessity (including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures); documentation should be legible, maintained in the medical record, and made available upon request.
Removed CPT code 19380 from the Applicable Codes section; guidance notes not to bill CPT 19380 under this policy as it was removed effective 2026-02-01 and to verify federal, state, or contractual requirements which may differ.
Updated Supporting Information sections: Clinical Evidence, FDA, and References to reflect the most current information; previous policy version CS011IN.09 archived.
Painful scars or donor site scar revisions must meet reconstructive definition to be considered for coverage