R414-1-29. Medicaid Policy for Reconstructive and Cosmetic Procedures

  (1) Reconstructive or restorative services are medically necessary; and

  (a) performed on abnormal structures of the body to improve and restore bodily function; or

  (b) performed to correct deformity resulting from disease, trauma, congenital anomaly, or previous therapeutic intervention.

  (2) Medicaid does not cover cosmetic procedures performed with the primary intent to improve appearance, nor does it cover non-medically necessary procedures performed in the same episode as a covered procedure.

  (3) Coverage for reconstructive breast procedures related to cancer includes:

  (a) reconstruction of the breast on which the procedure is performed; and

  (b) reconstruction of the breast on which the procedure is not performed to produce a symmetrical appearance and prostheses.

  (4) Medicaid limits reconstructive breast surgeries to initial occurrences that may include multi-step procedures.

  (5) Medicaid does not cover repeat reconstructive breast procedures.