CurrentUnitedHealthcarePolicy MP.004.30

Breast Reduction Surgery (Reduction Mammaplasty)

UnitedHealthcare Medical Policy MP.004.30 describes coverage considerations for breast reduction surgery (reduction mammaplasty) for UnitedHealthcare Commercial and Individual Exchange plans, clarifies applicability of the Women's Health and Cancer Rights Act of 1998, and references InterQual criteria for clinical medical necessity determinations. Member-specific benefit plans govern final coverage.

Policy Summary

PayerUnitedHealthcare

PolicyBreast Reduction Surgery (Reduction Mammaplasty)

Policy CodePolicy MP.004.30

Change TypeRevised (references, benefit considerations, related policies)

Effective DateJun 1, 2025

Next Review Date

Key ActionVerify the member-specific benefit plan document and applicable federal or state mandates to determine whether breast reduction surgery is covered for the member; documentation of medical records may be required.

POLICY UPDATE CHANGES

Related Policies and Applicable Codes updated; removed reference link to Medical Policy titled Panniculectomy and Body Contouring Procedures; Benefit Considerations updated to note exclusions do not apply to gender dysphoria treatment when plan has such benefit; references updated.

1Primary CPT referenced

2ICD-10 codes referenced

1InterQual criteria referenced

Coverage Summary & Criteria

UnitedHealthcare Medical Policy MP.004.30 addresses coverage considerations for breast reduction surgery (reduction mammaplasty) for UnitedHealthcare Commercial and Individual Exchange plans. Member-specific benefit plans govern final coverage and the member specific benefit plan document should be referenced to determine whether a given service is covered. The policy notes that qualifying breast reduction procedures that meet the Women's Health and Cancer Rights Act of 1998 requirements are covered, and InterQual clinical criteria are used to determine medical necessity for reduction mammaplasty.

Coverage Determination / Clinical Criteria

Coverage is determined by member-specific benefit plan and applicable laws. Breast reduction surgery may be covered when it meets Women's Health and Cancer Rights Act requirements or when InterQual criteria for reduction mammaplasty (female/adolescent/female) determine medical necessity.

ANY of the following

Breast reduction surgery that qualifies under the Women's Health and Cancer Rights Act of 1998 is covered (all plans).
Breast reduction surgery determined to be reconstructive and medically necessary per InterQual CP: Procedures - Reduction Mammaplasty, Female, Adolescent or Reduction Mammaplasty, Female.

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Exclusions / Plan-Specific Exclusion

Most UnitedHealthcare plans have a specific exclusion; however exceptions exist as noted below.

ALL of the following

Most UnitedHealthcare plans exclude breast reduction surgery except as required by the Women's Health and Cancer Rights Act of 1998.
Some plans may still exclude breast reduction surgery even if surgery treats a physiologic functional impairment; coverage is plan-specific.
If a plan has a gender dysphoria treatment benefit, the usual exclusion for breast reduction surgery does not apply when surgery is for treatment of gender dysphoria.

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title": "Exclusions / Plan-Specific Exclusion

Prior Authorization & Documentation Requirements

Documentation Required

Confirm member-specific benefit and applicable law

Verify the member-specific benefit plan document and applicable federal or state mandates to determine whether breast reduction surgery is covered for the member; documentation of medical records may be required to assess whether clinical criteria are met.

19318
N62
N65.1

Prior Authorization

Use InterQual criteria for medical necessity

Use InterQual CP: Procedures (Reduction Mammaplasty, Female, Adolescent; Reduction Mammaplasty, Female) to support medical necessity determinations and potential prior authorization requests.

Documentation Required

Gender dysphoria treatment benefit handling

If surgery is for treatment of gender dysphoria and the plan has a gender dysphoria treatment benefit, document that the procedure is part of gender dysphoria treatment to avoid plan-level exclusion.

Policy Background & Definitions

Most UnitedHealthcare plans have a specific exclusion for breast reduction surgery except as required by the Women's Health and Cancer Rights Act of 1998. Benefit coverage for health services is determined by the member-specific benefit plan document and applicable federal or state mandates; medical records documentation may be required to assess whether clinical criteria are met but does not guarantee coverage.

Breast reduction surgery is considered reconstructive and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, UnitedHealthcare refers to the InterQual CP: Procedures for Reduction Mammaplasty (Female, Adolescent and Female) to support determinations and prior authorization requests. If a plan includes a gender dysphoria treatment benefit, the usual plan-level exclusion for breast reduction does not apply when surgery is part of gender dysphoria treatment.

Women's Health and Cancer Rights Act of 1998: "In general a group health plan, and a health insurance issuer providing health insurance coverage in connection with a group health plan, that provides medical and surgical benefits with respect to a Mastectomy shall provide, in case of a participant or beneficiary who is receiving benefits in connection with a Mastectomy and who elects breast reconstruction in connection with such Mastectomy, coverage for (1) all stages of reconstruction of the breast on which the Mastectomy has been performed; (2) surgery and reconstruction of the other breast to produce symmetrical appearance; and (3) prostheses and physical complications of Mastectomy, including lymphedemas in a manner determined in consultation with the attending physician and the patient."

Policy Changes

2025-06-01effectiveLatest

Policy MP.004.30 effective date.

06/01/2025revised

Archived previous policy version MP.004.29. Related Policies and Applicable Codes updated; removed reference link to Medical Policy titled Panniculectomy and Body Contouring Procedures; Benefit Considerations updated to note exclusions do not apply to gender dysphoria treatment when plan has such benefit; references updated.