Breast Procedures - MEDICAID - FLORIDA

This Humana Medicaid policy covers breast reconstruction (implant- and autologous-based), nipple reconstruction, certain mastopexy and contralateral reduction mammaplasty for symmetry when performed in the context of medically necessary mastectomy/lumpectomy, prophylactic mastectomy, or recent trauma. Capsulectomy, capsulotomy and implant removal are covered when implants were placed with medically necessary surgery and specified complications are present (eg, Baker III/IV contracture, extrusion, rupture confirmed by imaging, or refractory infection), and special pathologic criteria apply for BIA-ALCL and BIA-SCC. Notably, liposuction-only reduction mammaplasty, naturally occurring asymmetry, and indications not listed in the policy are considered not medically necessary.

"An individual has had any of the following: A medically necessary mastectomy or lumpectomy (regardless of the date of the mastectomy or lumpectomy)."