Breast Procedures - MEDICAID - VIRGINIA

This Humana Medicaid (VA) coverage policy allows breast reconstruction (including implants, tissue expanders, mastopexy, nipple reconstruction and selected reduction mammaplasty) when tied to medically necessary mastectomy/lumpectomy, prophylactic mastectomy, or recent trauma, and specifies indications for capsulectomy/capsulotomy/implant removal (eg, Baker III/IV contracture, rupture with imaging confirmation, refractory infection). The policy excludes procedures not listed (including liposuction-only breast reduction and naturally occurring asymmetry corrections), requires specific diagnostic confirmation (imaging, microbiology, pathology including CD30/ALK testing for BIA-ALCL), and mandates medical director review for certain reductions to preserve nipple viability.

"Reduction mammaplasty to preserve nipple viability prior to nipple-sparing mastectomy requires medical director review (restriction)."