AllWays Health Partners

Policy Number
006
Policy Issued In
Massachusetts
Last Update
Breast Reconstruction

AllWays Health Partners also covers medically necessary breast reconstruction surgery in the following instances:

1. For treatment other than cancer-related mastectomy/lumpectomy (photo documentation is required) for a member with:

a. Severe disfigurement from Poland Syndrome or other disease; OR

b. Gender dysphoria when a member is transitioning from male to female and meets relevant medical necessity criteria for coverage under the Gender Reassignment Treatment and the request is for augmentation mammoplasty.

c. Severe breast asymmetry of at least 2 cup difference in breast size in a female patient who has reached full physical maturity, i.e., tanner stage V, typically age 15 and older.