Mastectomy and Reconstructive Surgery

Policy ID: S-129-032

Section: Surgery

Effective Date: July 01, 2018

Revised Date: March 20, 2025

Revision Effective Date: April 01, 2025

Last Reviewed: May 13, 2025

Applies To: Commercial and Medicaid Expansion

Description

Mastectomy is the removal of all or part of a breast and is typically performed as a treatment for cancer, or in some cases for the treatment of benign disease.

Reconstructive breast surgery is defined as surgical procedures performed that 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.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

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:

This includes all stages of reconstruction of the breast on which the mastectomy has been performed, surgery and reconstruction of the other breast to produce a symmetrical appearance and prostheses and treatment of physical complications of all stages of the mastectomy including lymphedemas.
If additional surgery is required for either breast for treatment of physical complications of the implant or reconstruction, surgery on the other breast to produce a symmetrical appearance is reconstructive at that point as well.
Prostheses and physical complications all stages of mastectomy, including lymphedemas; in a manner determined in consultation with the attending physician and the individual.
Cancer does not have to be the reason for the mastectomy.
The mandate applies to men, as well as women.

Mastectomy

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 individual 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:

When the individual is symptomatic;* and
Has been unresponsive to conservative treatment**; and/or
A biopsy has been performed.

*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

Mastectomy for fibrocystic breasts not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

19301

19302

19303

19305

19306

19307

Nipple Sparing Mastectomy (NSM)

Nipple sparing/skin sparing mastectomy may be considered medically necessary when there is no cancer involving the skin, nipple or areola.

NSM not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

19303

Removal of Breast Implant

Removal of a silicone gel-filled breast implant may be considered medically necessary:

In all cases for a documented implant rupture, infection, extrusion, Baker class IV contracture, in cases of surgical treatment of breast cancer.

Removal of a saline-filled breast implant may be considered medically necessary for EITHER of the following indications:

In a documented implant rupture for those individuals who had originally undergone breast implantation for reconstructive purposes; or
In cases of infection, extrusion, Baker class IV contracture, or surgical treatment of breast cancer.

Removal of a breast implant associated with a Baker class III contracture may be considered medically necessary:

In those individuals who had originally undergone breast implantation for reconstructive purposes.

The following indications for removal of breast implants are considered not medically necessary:

Systemic symptoms, attributed to connective tissue diseases, autoimmune diseases, etc.; or
Individual's anxiety; or
Baker class III contractures in individuals with implants for cosmetic purposes; or
Rupture of a saline implant in individuals with implants for cosmetic purposes; or
Pain not related to contractures or rupture.

Removal of breast implant not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

19328

19330

19370

19371

Reconstructive Surgery

Reconstructive breast surgery may be considered medically necessary for ANY of the following indications:

After a medically necessary mastectomy; or
Accidental injury; or
Trauma.

Reconstructive breast surgery after removal of an implant may be considered medically necessary:

Only in those individuals who had originally undergone breast implantation for reconstructive purposes.

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.

Reconstructive breast surgery not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

11920

11921

11922

15771

15772

19316

19318

19325

19328

19330

19340

19342

19350

19357

19361

19364

19367

19368

19369

19380

19396

19499

S2066

S2067

S2068

Surgery on the Contralateral Breast to Produce Symmetry

Surgery* on the contralateral breast to produce a symmetrical appearance during all stages of mastectomy may be considered reconstructive and medically necessary for one (1) or more of the following:

When the implant was originally placed for reconstructive purposes in an individual with a history of mastectomy, lumpectomy or treatment of breast cancer.
Individual has a history of mastectomy, lumpectomy or treatment of breast cancer.

* Types of reconstructive surgical procedures on the breast include, but are not limited to:

Nipple/areola reconstruction.
Nipple tattooing will be covered if the medical necessity criteria for reconstructive breast surgery are met.
- Nipple tattooing is considered cosmetic for all other indications.
Transverse rectus abdominis myocutaneous flap (TRAM), latissimus dorsi flap or free flap.
Preparation of moulage for custom breast implant.
Augmentation mammoplasty.
Reduction mammoplasty.
Mastopexy.

Surgery on the contralateral breast to produce symmetry not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

11920

11921

11922

15771

15772

19316

19318

19325

19328

19330

19340

19342

19350

19357

19361

19364

19367

19368

19369

19380

19396

19499

S2066

S2067

S2068

Breast Prosthetics

The following breast prosthetics are medically necessary:

Breast prosthesis, mastectomy bra.
Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral.
Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral.
Breast prosthesis, mastectomy form.
Breast prosthesis, silicone or equal.
Breast prosthesis, not otherwise specified.
Adhesive skin support attachment for use with external breast prosthesis, each.
External breast prosthesis garment, with mastectomy form, post mastectomy.
Custom breast prosthesis, post mastectomy, molded to individual model.
Implantable breast prosthesis, silicone or equal.
Camisole, post-mastectomy.
Breast prosthesis, silicone or equal, with integral adhesive.
Nipple prosthesis, reusable, any type, each.
Custom artificial devices.

NOTE:

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.

Procedure Codes

19325

L8000

L8001

L8002

L8015

L8020

L8030

L8031

L8032

L8033

L8035

L8039

L8600

A4280

S8460

Outpatient HCPCS (C Codes)

C1789

TableS-129

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/

Silicone

Reconstruction/

Saline

Cosmetic/Silicone

Cosmetic/Saline

Absolute Medical Indications

Rupture*

yes

Baker class IV contracture

yes

Recurrent infection

yes

Extruded implant

yes

Surgery for breast cancer

yes

Other Indications

Baker class III contractures***

yes

Pain**

Post-Explanation Procedures

Reimplantation of implants

yes

Autologous reconstruction

yes

* 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.

L8000

Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type

Up to four (4)
Includes codes L8001, L8002, L8015, and S8460.

Up to two (2) every 12 months
Includes codes L8001, L8002, L8015, and S8460.

L8001

Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type

Up to four (4)
Includes codes L8000, L8002, L8015, and S8460.

Two (2) every 12 months
Including codes L8000, L8002, L8015, and S8460.

L8002

Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type

Up to four (4)
Includes codes L8000, L8001, L8015, and S8460.

Two (2) every 12 months
Includes codes L8000, L8001, L8015, and S8460.

L8015

External breast prosthesis garment, with mastectomy form, post mastectomy

Up to four (4)
Includes codes L8000, L8001, L8002, and S8460.

Two (2) every 12 months
Includes codes L8000, L8001, L8002, and S8460.

L8020

Breast prosthesis, mastectomy form

Two (2) within 12 months for fabric, foam, or fiber-filled breast prostheses per affected side.
One (1) within 24 months for silicone prostheses per affected side.
Includes codes L8030, L8031, L8032, L8035, and L8039.

Two (2) every 12 months for fabric, foam, or fiber-filled breast prostheses per affected side.
One (1) every 24 months for silicone prostheses per affected side.
Includes codes L8030, L8031, L8032, L8035, and L8039.

L8030

Breast prosthesis, silicone or equal, without integral adhesive

One (1) per affected side within 24 months
Includes codes L8030 and L8035.

One (1) per affected side every 24 months,
Includes codes L8030 and L8035.

L8031

Breast prosthesis, silicone or equal, with integral adhesive

One (1) per affected side within 24 months
Includes codes L8030 and L8035.

One (1) per affected side every 24 months
Includes codes L8030 and L8035.

L8032

Nipple prosthesis, reusable, any type, each

One (1) per affected side every three (3) months.

One (1) per affected side every three (3) months.

L8035

Custom breast prosthesis, post mastectomy, molded to individual model

Two (2) within 12 months for fabric, foam, or fiber-filled breast prostheses per affected side.
One (1) within 24 months for silicone prostheses per affected side.
Includes codes L8020, L8030, L8031, L8032, and L8039.

Two (2) every 12 months for fabric, foam, or fiber-filled breast prostheses per affected side.
One (1) every 24 months for silicone prostheses per affected side.
Includes codes L8020, L8030, L8031, L8032, and L8039.

L8039

Breast prosthesis, not otherwise specified

Two (2) within 12 months for fabric, foam, or fiber-filled breast prostheses per affected side.
One (1) within 24 months for silicone prostheses per affected side.
Includes codes L8020, L8030, L8031, L8032, and L8035.

Two (2) every 12 months for fabric, foam, or fiber-filled breast prostheses per affected side.
One (1) every 24 months for silicone prostheses per affected side.
Includes codes L8020, L8030, L8031, L8032, and L8035.

A4280

Adhesive skin support attachment for use with external breast prosthesis, each

No quantity limits.

S8460

Camisole, postmastectomy

Up to four (4)
Includes codes L8000, L8001, L8002, and L8015.

Two (2) every 12 months
Includes codes L8000, L8001, L8002, and L8015.

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-14-2019 Revised policy

Incorporated Table into policy; and
Removed procedure code 19304; and
Added Procedure code L8033

Internal Medical Policy Committee 11-19-2020 - Revised policy

Updated Criteria

Internal Medical Policy Committee 11-23-2021 - Annual Review, no changes in criteria

Internal Medical Policy Committee 3-23-2022 - Revised policy

Updated with clarifying language

Internal Medical Policy Committee 11-29-2022 - Coding update - Effective November 30, 2022

Added procedure code 19371

Internal Medical Policy Committee 5-23-2023 - Coding update - Effective July 03, 2023

Added procedure codes 15771; and 15772

Internal Medical Policy Committee 3-19-2024 Coding update - Effective May 06, 2024

Added procedure codes 19370; and 19380; and
Added Policy Application

Internal Medical Policy Committee 9-17-2024 Revision with Coding update - Effective November 04, 2024

Added bullet point under 'Surgery on the Contralateral Breast to Produce Symmetry' section; and
Updated verbiage; and
Removed procedure code 19324

Internal Medical Policy Committee 5-13-2025 Coding update - Effective April 01, 2025

Removed procedure code L8010; and
Removed bullet breast prosthesis, mastectomy sleeve

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-129-031

Section: Surgery

Effective Date: July 01, 2018

Revised Date: August 21, 2024

Revision Effective Date: November 04, 2024

Last Reviewed: September 17, 2024

Archived Date: March 31, 2025

Applies To: Commercial and Medicaid Expansion

Description

Mastectomy is the removal of all or part of a breast and is typically performed as a treatment for cancer, or in some cases for the treatment of benign disease.

Lumpectomy is the removal of the breast tumor and surrounding tissue.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

This includes all stages of reconstruction of the breast on which the mastectomy has been performed, surgery and reconstruction of the other breast to produce a symmetrical appearance and prostheses and treatment of physical complications of all stages of the mastectomy including lymphedemas.
If additional surgery is required for either breast for treatment of physical complications of the implant or reconstruction, surgery on the other breast to produce a symmetrical appearance is reconstructive at that point as well.
Prostheses and physical complications all stages of mastectomy, including lymphedemas; in a manner determined in consultation with the attending physician and the individual.
Cancer does not have to be the reason for the mastectomy.
The mandate applies to men, as well as women.

Mastectomy

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 individual 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:

When the individual is symptomatic;* and
Has been unresponsive to conservative treatment**; and/or
A biopsy has been performed.

*Symptoms of fibrocystic breasts include, but are not limited to: breast engorgement attended by pain and tenderness, generalized lumpiness or isolated mass or cyst.

Mastectomy for fibrocystic breasts not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

19301

19302

19303

19305

19306

19307

Nipple Sparing Mastectomy (NSM)

Nipple sparing/skin sparing mastectomy may be considered medically necessary when there is no cancer involving the skin, nipple or areola.

NSM not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

19303

Removal of Breast Implant

Removal of a silicone gel-filled breast implant may be considered medically necessary:

In all cases for a documented implant rupture, infection, extrusion, Baker class IV contracture, in cases of surgical treatment of breast cancer.

Removal of a saline-filled breast implant may be considered medically necessary for EITHER of the following indications:

In a documented implant rupture for those individuals who had originally undergone breast implantation for reconstructive purposes; or
In cases of infection, extrusion, Baker class IV contracture, or surgical treatment of breast cancer.

Removal of a breast implant associated with a Baker class III contracture may be considered medically necessary:

In those individuals who had originally undergone breast implantation for reconstructive purposes.

The following indications for removal of breast implants are considered not medically necessary:

Systemic symptoms, attributed to connective tissue diseases, autoimmune diseases, etc.; or
Individual's anxiety; or
Baker class III contractures in individuals with implants for cosmetic purposes; or
Rupture of a saline implant in individuals with implants for cosmetic purposes; or
Pain not related to contractures or rupture.

Removal of breast implant not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

19328

19330

19370

19371

Reconstructive Surgery

Reconstructive breast surgery may be considered medically necessary for ANY of the following indications:

After a medically necessary mastectomy; or
Accidental injury; or
Trauma.

Reconstructive breast surgery after removal of an implant may be considered medically necessary:

Only in those individuals who had originally undergone breast implantation for reconstructive purposes.

Reconstruction may be performed by an implant-based approach or through the use of autologous tissue.

Refer to Table Attachment for a chart to assist with medical necessity determination for implant removal.

Reconstructive breast surgery not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

11920

11921

11922

15771

15772

19316

19318

19325

19328

19330

19340

19342

19350

19357

19361

19364

19367

19368

19369

19380

19396

19499

S2066

S2067

S2068

Surgery on the Contralateral Breast to Produce Symmetry

Surgery* on the contralateral breast to produce a symmetrical appearance during all stages of mastectomy may be considered reconstructive and medically necessary for one (1) or more of the following:

When the implant was originally placed for reconstructive purposes in an individual with a history of mastectomy, lumpectomy or treatment of breast cancer.
Individual has a history of mastectomy, lumpectomy or treatment of breast cancer.

* Types of reconstructive surgical procedures on the breast include, but are not limited to:

Nipple/areola reconstruction.
Nipple tattooing will be covered if the medical necessity criteria for reconstructive breast surgery are met.
- Nipple tattooing is considered cosmetic for all other indications.
Transverse rectus abdominis myocutaneous flap (TRAM), latissimus dorsi flap or free flap.
Preparation of moulage for custom breast implant.
Augmentation mammoplasty.
Reduction mammoplasty.
Mastopexy.

Surgery on the contralateral breast to produce symmetry not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

11920

11921

11922

15771

15772

19316

19318

19325

19328

19330

19340

19342

19350

19357

19361

19364

19367

19368

19369

19380

19396

19499

S2066

S2067

S2068

Breast Prosthetics

The following breast prosthetics are medically necessary:

Breast prosthesis, mastectomy bra.
Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral.
Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral.
Breast prosthesis, mastectomy sleeve.
Breast prosthesis, mastectomy form.
Breast prosthesis, silicone or equal.
Breast prosthesis, not otherwise specified.
Adhesive skin support attachment for use with external breast prosthesis, each.
External breast prosthesis garment, with mastectomy form, post mastectomy.
Custom breast prosthesis, post mastectomy, molded to individual model.
Implantable breast prosthesis, silicone or equal.
Camisole, post-mastectomy.
Breast prosthesis, silicone or equal, with integral adhesive.
Nipple prosthesis, reusable, any type, each.
Custom artificial devices.

NOTE:

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.

Procedure Codes

19324

19325

L8000

L8001

L8002

L8010

L8015

L8020

L8030

L8031

L8032

L8033

L8035

L8039

L8600

A4280

S8460

Outpatient HCPCS (C Codes)

C1789

TableS-129

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/

Silicone

Reconstruction/

Saline

Cosmetic/Silicone

Cosmetic/Saline

Absolute Medical Indications

Rupture*

yes

Baker class IV contracture

yes

Recurrent infection

yes

Extruded implant

yes

Surgery for breast cancer

yes

Other Indications

Baker class III contractures***

yes

Pain**

Post-Explanation Procedures

Reimplantation of implants

yes

Autologous reconstruction

yes

***Contractures have been graded according to the Baker Classification which is outlined below:

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.

L8000

Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type

Up to four (4)
Includes codes L8001, L8002, L8010, L8015, and S8460.

Up to two (2) every 12 months
Includes codes L8001, L8002, L8010, L8015, and S8460.

L8001

Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type

Up to four (4)
Includes codes L8000, L8002, L8010, L8015, and S8460.

Two (2) every 12 months
Including codes L8000, L8002, L8010, L8015, and S8460.

L8002

Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type

Up to four (4)
Includes codes L8000, L8001, L8010, L8015, and S8460.

Two (2) every 12 months
Includes codes L8000, L8001, L8010, L8015, and S8460.

L8010

Breast prosthesis, mastectomy sleeve

Up to four (4)
Includes codes L8000, L8001, L8002, L8015, and S8460.

Two (2) every 12 months
Includes codes L8000, L8001, L8002, L8015, and S8460.

L8015

External breast prosthesis garment, with mastectomy form, post mastectomy

Up to four (4)
Includes codes L8000, L8001, L8002, L8010, and S8460.

Two (2) every 12 months
Includes codes L8000, L8001, L8002, L8010, and S8460.

L8020

Breast prosthesis, mastectomy form

Two (2) within 12 months for fabric, foam, or fiber-filled breast prostheses per affected side.
One (1) within 24 months for silicone prostheses per affected side.
Includes codes L8030, L8031, L8032, L8035, and L8039.

Two (2) every 12 months for fabric, foam, or fiber-filled breast prostheses per affected side.
One (1) every 24 months for silicone prostheses per affected side.
Includes codes L8030, L8031, L8032, L8035, and L8039.

L8030

Breast prosthesis, silicone or equal, without integral adhesive

One (1) per affected side within 24 months
Includes codes L8030 and L8035.

One (1) per affected side every 24 months,
Includes codes L8030 and L8035.

L8031

Breast prosthesis, silicone or equal, with integral adhesive

One (1) per affected side within 24 months
Includes codes L8030 and L8035.

One (1) per affected side every 24 months
Includes codes L8030 and L8035.

L8032

Nipple prosthesis, reusable, any type, each

One (1) per affected side every three (3) months.

One (1) per affected side every three (3) months.

L8035

Custom breast prosthesis, post mastectomy, molded to individual model

Two (2) within 12 months for fabric, foam, or fiber-filled breast prostheses per affected side.
One (1) within 24 months for silicone prostheses per affected side.
Includes codes L8020, L8030, L8031, L8032, and L8039.

Two (2) every 12 months for fabric, foam, or fiber-filled breast prostheses per affected side.
One (1) every 24 months for silicone prostheses per affected side.
Includes codes L8020, L8030, L8031, L8032, and L8039.

L8039

Breast prosthesis, not otherwise specified

Two (2) within 12 months for fabric, foam, or fiber-filled breast prostheses per affected side.
One (1) within 24 months for silicone prostheses per affected side.
Includes codes L8020, L8030, L8031, L8032, and L8035.

Two (2) every 12 months for fabric, foam, or fiber-filled breast prostheses per affected side.
One (1) every 24 months for silicone prostheses per affected side.
Includes codes L8020, L8030, L8031, L8032, and L8035.

A4280

Adhesive skin support attachment for use with external breast prosthesis, each

No quantity limits.

S8460

Camisole, postmastectomy

Up to four (4)
Includes codes L8000, L8001, L8002, L8010, and L8015.

Two (2) every 12 months
Includes codes L8000, L8001, L8002, L8010, and L8015.

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-14-2019 Revised policy

Incorporated Table into policy; and
Removed procedure code 19304; and
Added Procedure code L8033

Internal Medical Policy Committee 11-19-2020 - Revised policy

Updated Criteria

Internal Medical Policy Committee 11-23-2021 - Annual Review, no changes in criteria

Internal Medical Policy Committee 3-23-2022 - Revised policy

Updated with clarifying language

Internal Medical Policy Committee 11-29-2022 - Coding update - Effective November 30, 2022

Added procedure code 19371

Internal Medical Policy Committee 5-23-2023 - Coding update - Effective July 03, 2023

Added procedure codes 15771; and 15772

Internal Medical Policy Committee 3-19-2024 Coding update - Effective May 06, 2024

Added procedure codes 19370; and 19380; and
Added Policy Application

Internal Medical Policy Committee 9-17-2024 Revision with Coding update - Effective November 04, 2024

Added bullet point under "Surgery on the Contralateral Breast to Produce Symmetry" section; and
Updated verbiage; and
Removed procedure code 19324

Medical Policies Quick Search

Mastectomy and Reconstructive Surgery

Description

Policy Application

Criteria

Nipple Sparing Mastectomy (NSM)

Procedure Codes

Removal of Breast Implant

Procedure Codes

Reconstructive Surgery

Procedure Codes

Surgery on the Contralateral Breast to Produce Symmetry

Procedure Codes

Breast Prosthetics

Procedure Codes

Outpatient HCPCS (C Codes)

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

Nipple Sparing Mastectomy (NSM)

Procedure Codes

Removal of Breast Implant

Procedure Codes

Reconstructive Surgery

Procedure Codes

Surgery on the Contralateral Breast to Produce Symmetry

Procedure Codes

Breast Prosthetics

Procedure Codes

Outpatient HCPCS (C Codes)

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer