Mastectomy is the removal of all or part of a breast and is typically performed as a treatment for cancer, or sometimes for the treatment of benign disease.
Reconstructive breast surgery is defined as those surgical procedures performed that are designed to restore the normal appearance of a breast. Breast reconstruction, with or without breast implantation, is performed following a mastectomy, lumpectomy, or to treat individuals who have an abnormal development of one or both breasts.
Lumpectomy is the removal of the breast tumor and surrounding tissue.
Mastectomy may be considered medically necessary for the symptoms and diagnosis, or treatment of the member’s condition, illness, or injury.
The type of mastectomy (subcutaneous, partial, modified, or radical) and the timing of the surgery vary for each patient and are determined by the surgeon.
Mastectomy for Fibrocystic Breasts
Fibrocystic breasts are considered a condition or a disorder with or without mild to severe symptoms.
Mastectomy for fibrocystic breasts may be considered medically necessary:
*Symptoms of fibrocystic breasts include, but are not limited to: breast engorgement attended by pain and tenderness, generalized lumpiness or isolated mass or cyst.
**Conservative treatment for fibrocystic breasts consists of, but is not limited to: support bras, avoiding trauma, avoiding caffeine, medication for pain, anti-inflammatory drugs, hormonal manipulation, use of vitamin E, use of diuretics, and salt restrictions.
Nipple sparing/skin sparing mastectomy may be considered medically necessary when there is no cancer involving the skin, nipple or areola.
Removal of a silicone gel-filled breast implant may be considered medically necessary:
Removal of a saline-filled breast implant may be considered medically necessary for EITHER of the following indications:
Removal of a breast implant associated with a Baker class III contracture may be considered medically necessary:
The following indications for removal of breast implants are considered not medically necessary:
Reconstructive breast surgery may be considered medically necessary for ANY of the following indications:
Reconstructive breast surgery after removal of an implant may be considered medically necessary:
Reconstruction may be performed by an implant-based approach or through the use of autologous tissue.
Removal of implants requires documentation of the original indication for implantation and the type of implant, either saline- or silicone gel-filled, and the current symptoms, either local or systemic.
Refer to Table Attachment for a chart to assist with medical necessity determination for implant removal.
Surgery on the Contralateral Breast to Produce Symmetry
Surgery* on the contralateral breast to produce a symmetrical appearance after removal of an implant and reimplantation may be considered reconstructive and medically necessary:
* Types of reconstructive surgical procedures on the diseased breast include, but are not limited to:
Services that do not meet the criteria of this policy will be considered not medically necessary.
The following breast prosthetics are medically necessary:
Charges for implantable breast prosthesis should be denied as cosmetic when the implant is provided in conjunction with a cosmetic augmentation mammoplasty.
Please see Table Attachment for quantity limits.
The Women’s Health and Cancer Rights Act of 1998 (WHCRA) is federal legislation that provides that any individual, with insurance coverage who is receiving benefits in connection with a mastectomy covered by their benefit plan (whether or not for cancer) who elects breast reconstruction, must receive coverage for the reconstructive services as provided by WHCRA. This mandate further defines coverage for the following:
Outpatient HCPCS (C Codes)
The following chart should facilitate determination of the medical necessity breast implant removal:
Yes– indicates the removal would be considered medically necessary, given the symptoms, type of implant, and original indication for implantation.
No- indicates the removal would be considered not medically necessary.
|Indication for Breast Implant Removal||Reconstruction/
|Absolute Medical Indications|
|Baker class IV contracture||yes||yes||yes||yes|
|Surgery for breast cancer||yes||yes||yes||yes|
|Baker class III contractures***||yes||yes||no||no|
|Reimplantation of implants||yes||yes||no||no|
* Rupture of implants requires documentation with an imaging study, such as mammography, magnetic resonance imaging, or ultrasonography. Lack of imaging confirmation of rupture in association with persistent local symptoms requires case by case consideration.
** Pain as an isolated symptom is an inadequate indication for implant removal. The pain should be related to the Baker classification or a diagnosis of rupture.
***Contractures have been graded according to the Baker Classification which is outlined below:
Grade I: Augmented breast feels as soft as a normal breast.
Grade II: Breast is less soft and the implant can be palpated but is not visible.
Grade III: Breast is firm, palpable, and the implant (or its distortion) is visible.
Grade IV: Breast is hard, painful, cold, tender, and distorted.
Quantity Level Limits For Breast Prosthetics
|Procedure Code||Definition||Less than or equal to 12 months post mastectomy.||Greater than or equal to 13 months post mastectomy.|
|Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type||
|L8001||Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type||
|L8002||Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type||
|L8010||Breast prosthesis, mastectomy sleeve||
|L8015||External breast prosthesis garment, with mastectomy form, post mastectomy||
|L8020||Breast prosthesis, mastectomy form||
|L8030||Breast prosthesis, silicone or equal, without integral adhesive||
|L8031||Breast prosthesis, silicone or equal, with integral adhesive||
|L8032||Nipple prosthesis, reusable, any type, each||
|L8035||Custom breast prosthesis, post mastectomy, molded to patient model||
|L8039||Breast prosthesis, not otherwise specified||
|A4280||Adhesive skin support attachment for use with external breast prosthesis, each||No quantity limits.||No quantity limits.|