Breast Reconstruction - MEDICAID - OKLAHOMA

This policy covers breast reconstruction surgery and related procedures — including autologous flap reconstructions (eg, DIEP, DCIA), tissue expanders, implant-based reconstruction, nipple/areola reconstruction and tattooing, revisions, contralateral symmetry procedures, implant removal/capsulectomy/capsulotomy, and staged reconstruction — following mastectomy, prophylactic mastectomy, or trauma. Coverage is limited to cases meeting specific medical criteria (choice of modality individualized), requires diagnostic confirmation for implant complications (eg, MRI/ultrasound for rupture; microbiologic proof or infection refractory to antibiotics), limits total capsulectomy and BIA-ALCL treatment to pathologically confirmed cases (CD30/ALK testing), excludes cosmetic indications (eg, natural asymmetry, inverted nipples), and considers lymphatic microvascular surgery experimental.

"Infection confirmed by microbiological analysis of peri-implant fluid aspirate"