| Surgery Section - Reconstructive Breast Surgery/Mastopexy,
and Management of Breast Implants
| Topic: Reconstructive Breast
Surgery/Mastopexy, and Management of Breast Implants |
Date of Origin: 01/1996 |
| Section: Surgery |
Policy No: 40 |
| Approved Date: 12/09/2008 |
Effective Date: 05/01/2009 |
| Next Review Date: 05/2011 |
IMPORTANT REMINDER
Regence Medical Policies are developed to provide guidance for members and providers regarding
coverage in accordance with contract terms. Benefit determinations are based in all cases on
the applicable contract language. To the extent there may be any conflict between the Medical
Policy and contract language, the contract language takes precedence.
PLEASE NOTE: Contracts exclude from coverage, among other things, services or procedures that
are considered investigational or cosmetic. Providers may bill members for services or
procedures that are considered investigational or cosmetic. Providers are encouraged to inform
members before rendering such services that the members are likely to be financially responsible
for the cost of these services.
Description
Reconstructive breast surgery is defined as those
surgical procedures which are intended to restore the
normal appearance of the breast after surgery, accidental
injury, or trauma. The most common indication for reconstructive
breast surgery is mastectomy. In contrast, cosmetic
breast surgery is defined as surgery intended to alter
or enhance the appearance of a breast, which does not
have a significantly altered appearance due to surgery,
accidental injury, or trauma. Reduction mammoplasty
and surgery to alter the appearance of a congenital
breast abnormality are examples of breast surgeries
which may be cosmetic. (See Surgery Policy No. 60,
Reduction Mammoplasty and Surgery Policy No. 12, Cosmetic
and Reconstructive Surgery).
The most common type of reconstructive breast surgery
is insertion of a silicone gel-filled or saline-filled
breast implant, either inserted immediately at the
time of mastectomy -or sometime afterward in conjunction
with the previous use of a tissue expander -. Significant
local complications of breast implants, such as contracture,
may require removal of the implant.
Other types of reconstruction include nipple/areola
reconstruction, nipple tattooing, and/or the use of
autologous tissue, such as a transverse rectus abdominis
myocutaneous flap (TRAM procedure) or a latissimus
dorsi flap. In addition, mastopexy, reduction mammoplasty,
or implant on the contralateral breast may be performed
in order to achieve symmetry with the reconstructed
breast.
Policy/Criteria
| I. |
Reconstructive Breast Surgery of
a Diseased or Injured Breast |
| |
Reconstructive breast surgery of
a diseased or injured breast may be considered
medically necessary when either of the following
criteria is met and the treating physician recommends
it: |
| |
A. |
After mastectomy |
| |
B. |
After accidental injury or trauma to the breast |
| II. |
Reconstructive Breast
Surgery to Achieve Symmetry |
| |
Reconstructive breast
surgery of an unaffected breast to achieve symmetry
with the contralateral breast which has been reconstructed
following mastectomy for disease, injury, or trauma
may be considered medically necessary when the
treating physician recommends it. |
| III. |
Explantation of Breast
Implants |
| |
A. |
Explantation of a breast implant(s)
is considered medically necessary, when the implant(s)
was/were placed after mastectomy, accidental injury,
or trauma. |
| |
B. |
Application of the above policy
regarding explantation of implants requires documentation
of the original indication for implantation. |
Note that contractual limitations and exclusions may
apply to both reconstructive and cosmetic procedures,
- to illnesses and conditions initially occurring prior
to coverage, and to complications of non-covered procedures.
Position Summary
This policy is written to assist in interpreting Public
Law 105-277, the Women's Health and Cancer Rights Act
of 1998 which requires all health insurance carriers
that cover mastectomies to also cover the following in
a manner determined in consultation with the attending
physician and patient:
- All stages of reconstruction of the breast on which
the mastectomy was performed
- Surgery and reconstruction of the contralateral
breast to produce a symmetrical appearance
- Prostheses
- Treatment of physical complications of mastectomy,
including lymphedema
References
Cross References
Cosmetic
and Reconstructive Surgery, Regence Medical
Policy Manual, Surgery, Policy No. 12
Reduction
Mammoplasty, Regence Medical Policy Manual, Surgery,
Policy No. 60
| Codes |
Number |
Description |
| CPT |
11920
|
Tattooing, intradermal introduction of insoluble
opaque pigments to correct color defects of skin,
including micropigmentation; 6.0 sq. cm or less |
| |
11970 |
Replacement of tissue expander with permanent
prosthesis |
| |
11971 |
Removal of tissue expander(s) without insertion
of prosthesis |
| |
19316
|
Mastopexy |
| |
19318 |
Reduction mammaplasty |
| |
19324 |
Mammaplasty, augmentation; without
prosthetic implant |
| |
19325 |
Mammaplasty, augmentation; with
prosthetic implant |
| |
19328 |
Removal of intact mammary implant |
| |
19330 |
Removal of mammary implant material |
| |
19340 |
Immediate insertion of breast prosthesis following
mastopexy, mastectomy, or in reconstruction |
| |
19342 |
Delayed insertion of breast prosthesis following
mastopexy, mastectomy, or in reconstruction |
| |
19350
|
Nipple/areola reconstruction |
| |
19357 |
Breast reconstruction, immediate or delayed,
with tissue expander, including subsequent expansion |
| |
19361 |
Breast reconstruction with latissimus dorsi flap,
without prosthetic implant |
| |
19364 |
Breast reconstruction with free flap |
| |
19366 |
Breast reconstruction with other technique |
| |
19367 |
Breast reconstruction with transverse rectus
abdominis myocutaneous flap (TRAM) single pedicle,
including closure of donor site |
| |
19368 |
;with microvascular anastomosis (supercharging)
|
| |
19369 |
Breast reconstruction with transverse rectus
abdominis myocutaneous flap (TRAM) double pedicle,
including closure of donor site |
| |
19370 |
Open periprosthetic capsulotomy,
breast |
| |
19371 |
Periprosthetic capsulotomy, breast |
| |
19380 |
Revision of reconstructed breast |
| |
19396 |
Preparation of moulage for custom
breast implant |
| HCPCS |
L8039 |
Breast prosthesis, not otherwise specified |
| |
L8600 |
Implantable breast prosthesis, silicone or
equal |
| |
S2066 |
Breast reconstruction with gluteal artery perforator
(GAP) flap, including harvesting of the flap, microvascular
transfer, closure of donor site and shaping the
flap into a breast, unilateral |
| |
S2067 |
Breast reconstruction of a single breast with "stacked" deep
inferior epigastric perforator (DIEP) flap(s) and/or
gluteal artery perforator (GAP) flap(s), including
harvesting of the flap(s), microvascular transfer,
closure of donor site(s) and shaping the flap into
a breast, unilateral |
| |
S2068 |
Breast reconstruction with deep inferior epigastric
perforator (DIEP) flap or superficial inferior
epigastric artery (SIEA) flap, including harvesting
of the flap, microvascular transfer, closure of
donor site and shaping the flap into a breast,
unilateral |
Surgery Section Table of Contents 
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