Mastectomy and Reconstructive Surgery

Policy ID: S-129-028

Section: Surgery

Effective Date: July 01, 2018

Revised Date: November 24, 2020

Revision Effective Date: January 04, 2021

Last Reviewed: November 19, 2020

Description

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.

Criteria

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 inconsultation 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

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.

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.

Procedure Codes

19328

19330

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.

Procedure Codes

11920	11921	11922	19316	19318	19324	19325
19328	19330	19340	19342	19350	19357	19361
19364	19367	19368	19369	19396	19499	S2066
S2067	S2068

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:

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

* Types of reconstructive surgical procedures on the diseased 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.

Services that do not meet the criteria of this policy will be considered not medically necessary.

Procedure Codes

11920	11921	11922	19316	19318	19324	19325
19328	19330	19340	19342	19350	19357	19361
19364	19367	19368	19369	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	yes	yes	no
Baker class IV contracture	yes	yes	yes	yes
Recurrent infection	yes	yes	yes	yes
Extruded implant	yes	yes	yes	yes
Surgery for breast cancer	yes	yes	yes	yes
Other Indications
Baker class III contractures***	yes	yes	no	no
Pain**	no	no	no	no
Post-Explanation Procedures
Reimplantation of implants	yes	yes	no	no
Autologous reconstruction	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.
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.	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 incorporate Table into policy; removal of procedure code 19304; Add Procedure code L8033

Internal Medical Policy Committee 11-19-2020 Criteria updated

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.

Section: Surgery

Effective Date: January 01, 2020

Revised Date: November 14, 2019

Last Reviewed: November 14, 2019

Archived Date: January 03, 2021

Description

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.

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

Criteria

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 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:

When the patient 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.

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.

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 patients 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 patients 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
Patient anxiety; or
Baker class III contractures in patients with implants for cosmetic purposes; or
Rupture of a saline implant in patients with implants for cosmetic purposes; or
Pain not related to contractures or rupture.

Procedure Codes

19328

19330

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 patients 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.

Procedure Codes

11920	11921	11922	19316	19318	19324	19325
19328	19330	19340	19342	19350	19357	19361
19364	19367	19368	19369	19396	19499	S2066
S2067	S2068

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:

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

* Types of reconstructive surgical procedures on the diseased 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.

Services that do not meet the criteria of this policy will be considered not medically necessary.

Procedure Codes

11920	11921	11922	19316	19318	19324	19325
19328	19330	19340	19342	19350	19357	19361
19364	19367	19368	19369	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 patient model.
Implantable breast prosthesis, silicone or equal.
Camisole, post-mastectomy.
Breast prosthesis, silicone or equal, with integral adhesive.
Nipple prosthesis, reusable, any type, each.

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

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 patient.
Cancer does not have to be the reason for the mastectomy.
The mandate applies to men, as well as women.

Outpatient HCPCS (C Codes)

C1789

Table S-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	yes	yes	no
Baker class IV contracture	yes	yes	yes	yes
Recurrent infection	yes	yes	yes	yes
Extruded implant	yes	yes	yes	yes
Surgery for breast cancer	yes	yes	yes	yes
Other Indications
Baker class III contractures***	yes	yes	no	no
Pain**	no	no	no	no
Post-Explantation Procedures
Reimplantation of implants	yes	yes	no	no
Autologous reconstruction	yes	yes	no	no

** 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, 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 patient 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.	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.

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