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State-specific UnitedHealthcare medical policy governing coverage and medical necessity criteria for breast reconstruction procedures, related adjunct procedures (nipple/areola creation, mastopexy, implant/tissue expander use, ADM), treatment of post-mastectomy complications (lymphedema, infection), implant removal for Allergan BIOCELL textured implants, and correction of inverted nipples or congenital anomalies — applicable only in Nebraska.
Medical Records Documentation Used for Reviews language added specifying documentation that may be required and that it does not guarantee coverage.
Supporting Information sections (Clinical Evidence, FDA, References) updated to reflect most current information.
This Nebraska-specific UnitedHealthcare medical policy (CS011NE.V) addresses coverage and medical necessity criteria for Breast Reconstruction. Effective date: November 1, 2025; Last review: November 1, 2025. Payer: UnitedHealthcare; Policy number: CS011NE.V.
Scope: Nebraska-only. Headline coverage stance: the policy treats breast reconstruction as reconstructive when it meets state criteria (per Nebraska DHHS Code 471-10) and specifically notes that removal of Allergan BIOCELL textured implants is covered as reconstructive.