CurrentUnitedHealthcarePolicy CS012LA.V

Breast Reduction Surgery (for Louisiana Only)

Defines Louisiana Medicaid coverage criteria for reduction mammaplasty (breast reduction) for non-reconstructive indications, including required clinical symptoms, duration, and other conditions for medical necessity. Applies only to UnitedHealthcare Community Plan members in Louisiana.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reduction Surgery (for Louisiana Only)

Policy CodePolicy CS012LA.V

Change TypeRevised references; archived prior version

Effective DateJun 1, 2025

Next Review Date

Key ActionProvider must document pubertal breast development completion, macromastia diagnosis with at least two qualifying symptoms present for >= 12 weeks, and the expected amount of tissue removal and its likelihood to alleviate symptoms.

POLICY UPDATE CHANGES

Supporting Information - Updated References section to reflect the most current information; archived previous policy version CS012LA.U.

1Covered procedure code

2Referenced ICD-10 codes

12Minimum symptom duration (weeks)

Coverage Summary & Criteria

This policy (Policy Number CS012LA.V, effective June 1, 2025) covers reduction mammaplasty for non-reconstructive indications for UnitedHealthcare Community Plan members in Louisiana when the specified medical necessity criteria are met. Coverage is covered_with_criteria and requires that pubertal breast development is complete, a diagnosis of macromastia with at least two qualifying symptoms present for >= 12 weeks, a reasonable likelihood symptoms are primarily due to macromastia, and that the planned amount of tissue removal is expected to alleviate the symptoms.

Medically necessary criteria for reduction mammaplasty

Reduction mammaplasty for purposes other than reconstruction is considered medically necessary when ALL of the following criteria are met:

ALL of the following

Pubertal breast development is complete.
ALL of the following
- At least 2 of
  - Chronic breast pain
  - Headache
  - Neck, shoulder, or back pain
  - Shoulder grooving from bra straps
  - Upper extremity paresthesia due to brachial plexus compression syndrome, secondary to the weight of the breasts being transferred to the shoulder strap area
  - Thoracic kyphosis
  - Persistent skin condition such as intertrigo in the inframammary fold that is unresponsive to medical management
  - Congenital breast deformity
There is a reasonable likelihood that the symptoms are primarily due to macromastia;
The amount of breast tissue to be removed is reasonably expected to alleviate the symptoms.

Documentation Requirements

Documentation Required

Document completion of pubertal breast development

Provider must document that pubertal breast development is complete as part of medical necessity determination.

Documentation Required

Document symptom history and duration

Provider must document diagnosis of macromastia and at least two qualifying symptoms with evidence they have persisted for at least 12 weeks and that symptoms are primarily due to macromastia.

Symptoms must be present for at least a 12-week duration
At least two of the listed symptoms are required

Documentation Required

Document expected tissue removal benefit

Provider must document the amount of breast tissue planned for removal and a reasonable expectation that it will alleviate the documented symptoms.

Policy Context

This is a Louisiana-only UnitedHealthcare Medical Policy that defines Louisiana Medicaid coverage criteria for reduction mammaplasty and is intended to assist in interpreting benefit coverage. The policy is subordinate to applicable federal, state, or contractual requirements that govern benefit coverage, and those requirements take precedence in the event of a conflict. It applies specifically to UnitedHealthcare Community Plan members in Louisiana.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reduction Surgery (for Louisiana Only)

Policy CodePolicy CS012LA.V

Change TypeRevised references; archived prior version

Effective DateJun 1, 2025

Next Review Date

On This Page

N62	Hypertrophy of breast
N65.1	Disproportion of reconstructed breast

OpenPayer

Breast Reduction Surgery (for Louisiana Only)

Coverage Summary & Criteria

Documentation Requirements

Relevant Codes

Policy Context

Document Revisions