CurrentUnitedHealthcarePolicy CS012KS.02

Breast Reduction Surgery (for Kansas Only)

Policy governs medical necessity and coverage characterization for breast reduction (reduction mammaplasty) for members in the state of Kansas and delegates clinical criteria to InterQual CP: Reduction Mammaplasty (female and adolescent). It applies only to Kansas and references related UnitedHealthcare Kansas policies.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reduction Surgery (for Kansas Only)

Policy CodePolicy CS012KS.02

Change TypeRevised references

Effective DateJul 1, 2025

Next Review Date

Key ActionProviders must reference and meet the InterQual CP criteria (Reduction Mammaplasty, Female or Reduction Mammaplasty, Female, Adolescent) when requesting coverage for breast reduction surgery; medical necessity is determined by those criteria.

SourceLink

POLICY UPDATE CHANGES

Related Policies and Applicable Codes: removed reference link to the Panniculectomy and Body Contouring Procedures (for Kansas Only) policy.

1Primary CPT code referenced

2Referenced ICD-10 diagnoses

Coverage Summary

Policy Number: CS012KS.02; Effective Date: July 1, 2025. This policy governs medical necessity and coverage characterization for breast reduction (reduction mammaplasty) for members in the state of Kansas only. Clinical coverage criteria and the medical necessity determination are delegated to the InterQual CP content: Reduction Mammaplasty, Female and Reduction Mammaplasty, Female, Adolescent. Use this policy alongside applicable federal, state, and contractual benefit requirements when making coverage decisions.

Medical Necessity Determination (per InterQual)

Medical Necessity Determination

Coverage determination uses external InterQual criteria; breast reduction is considered reconstructive and medically necessary when InterQual criteria are met.

ALL of the following

Patient is covered under a UnitedHealthcare plan subject to Kansas state rules
Policy applies only to the state of Kansas and federal, state, or contractual benefit requirements govern coverage determinations.
InterQual CP: Reduction Mammaplasty, Female OR InterQual CP: Reduction Mammaplasty, Female, Adolescent criteria are met
InterQual is a proprietary clinical criteria tool used by UnitedHealthcare to determine medical necessity for procedures such as reduction mammaplasty.

Provider Actions & Prior Authorization

Documentation Required

Use InterQual criteria for medical necessity

Providers must reference and meet the InterQual CP criteria (Reduction Mammaplasty, Female or Reduction Mammaplasty, Female, Adolescent) when requesting coverage for breast reduction surgery (CPT 19318); medical necessity is determined by those InterQual criteria.

19318

Prior Authorization

Prior authorization requirement

Prior authorization/coverage determination should follow UnitedHealthcare procedures and the InterQual CP criteria for reduction mammaplasty; submitted documentation must support the InterQual criteria to establish medical necessity. This policy and requirement apply only to members in the state of Kansas.

19318
Applies to Kansas only

Background & Definitions

UnitedHealthcare considers breast reduction surgery reconstructive and medically necessary in certain circumstances. For clinical medical necessity criteria, this policy delegates to the InterQual CP content for Reduction Mammaplasty (Female) and Reduction Mammaplasty (Female, Adolescent). This policy applies only to the state of Kansas and should be used in conjunction with applicable federal, state, and contractual benefit requirements when determining coverage.

InterQual CP: Proprietary clinical criteria tool used by UnitedHealthcare to determine medical necessity for procedures such as reduction mammaplasty.

Revision History

07/01/2025revisedLatest

Related Policies and Applicable Codes: removed reference link to the Medical Policy titled Panniculectomy and Body Contouring Procedures (for Kansas Only).

07/01/2025revisedLatest

Supporting Information: archived previous policy version CS012KS.01; removed reference link per change detail.

07/01/2025effectiveLatest

Policy Number CS012KS.02 became effective (Breast Reduction Surgery for Kansas Only).

07/01/2025coverage_criteria_delegationLatest

Clinical coverage criteria delegated to InterQual CP: Reduction Mammaplasty, Female and Reduction Mammaplasty, Female, Adolescent for medical necessity determinations.