Breast Reconstruction - MEDICAID - OHIO

Breast reconstruction services—including autologous tissue reconstruction, implants, tissue expanders, nipple/areola reconstruction, revisions and related procedures—when medically necessary for Humana Healthy Horizons Medicaid members following mastectomy, prophylactic mastectomy, cancer treatment, or trauma. Coverage requires prior authorization and medical necessity documentation with individualized Medical Director review, is subject to OAC chapter 5160 and state mandates, and includes specific limits (e.g., trauma reconstructions within 12 months, standalone fat grafting and certain nipple procedures may require separate review or be excluded).

"Clinical justification that the service meets generally accepted standards of medical practice."

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