Reconstructive Breast Surgery

This policy covers medically necessary reconstructive breast surgery—including immediate or delayed implant-based reconstruction, tissue expanders, autologous flap procedures, fat grafting, nipple/areola reconstruction, contralateral procedures for symmetry, and revisions—after full or partial mastectomy, breast‑conserving surgery, trauma, accidental injury, or prophylactic mastectomy. Coverage is subject to state mandates (specific provisions for Illinois and Arkansas members), the member’s benefit plan/contract (which governs and may impose exclusions or limits), excludes purely cosmetic procedures and certain groups/services (e.g., ASO groups, transgender services per SUR717.001), and clinical factors such as post‑mastectomy radiotherapy timing can affect appropriateness.

"For Illinois (per Illinois Public Act 103-0123), coverage of medically necessary reconstructive services intended to restore physical appearance of body structures damaged by trauma."