Breast Reconstruction - MEDICAID - KENTUCKY

This policy covers breast reconstruction services including autologous tissue flaps (e.g., DIEP, TRAM, DCIA/Ruben's, GAP, PAP, SIEA, LD/TDAP, TUG), implant-based reconstruction, oncoplastic procedures, chest‑wall flat closure, revisions/contralateral symmetry procedures, and autologous fat grafting when performed as part of reconstruction. Coverage is for patients after a medically necessary mastectomy, lumpectomy, medically indicated prophylactic mastectomy or qualifying trauma (within 12 months) and includes key limits/requirements such as medical director review for stand‑alone fat grafting, imaging confirmation for implant rupture, Baker III/IV required for capsular contracture treatment, mandatory pathologic confirmation and total capsulectomy for BIA‑ALCL, exclusion of purely cosmetic procedures and implants placed solely for cosmetic reasons, and reinsertion only after medically necessary removal.

"Deep inferior epigastric perforator (DIEP) flap"