For services on or after December 20, 2007, see policy N-143.

The American Society of Plastic Surgeons (ASPS) defines cosmetic surgery as surgery performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.

The ASPS define reconstructive surgery as surgery performed to improve function of abnormal structures of the body, but may also be done to approximate a normal appearance.

For the purposes of this coverage policy, reconstructive breast surgery refers to surgery performed to correct or repair abnormal structures of the breast, caused by congenital defects, developmental abnormalities, trauma, infection, tumor or disease.

1. Reduction Mammoplasty - is considered reconstructive surgery and medically necessary for symptomatic macromastia patients when all of the following criteria are met:
   
   
   • The patient has significant symptoms that interfere with normal daily activities including at least one of the following:
     
     
     • Symptomatic neck, back or shoulder pain not related to other causes (e.g., poor posture, acute strains, poor lifting techniques)
       
       
     • Significant breast pain
       
       
     • Brachial plexus irritation
       
       
     • Clinical, nonseasonal submammary intertrigo
       
       
   • The amount of breast tissue anticipated to be removed is at least 350 grams per breast.
     
     
   • Conservative treatment has failed
     
     
     • Appropriate support bra
       
       
     • Conservative analgesia (NSAIDs)
       
       
     • In patients where obesity is a documented risk factor, a legitimate medically-based attempt to reduce and maintain weight
       
       
     • Intertrigo is refractory to, or recurrent following, a completed course of appropriate medical management
       
       
2. Breast Reconstruction - of the affected and contralateral unaffected breast following a medically necessary mastectomy is considered reconstructive and medically reasonable and necessary.
   
   

   All stages of reconstruction of the diseased breast, procedures to restore and achieve symmetry on the opposite breast (including augmentation, reduction, or mastopexy), prostheses, and treatment of any complications of mastectomy are considered reasonable and necessary.

   Nipple tattooing to recreate the nipple and/or areola is considered medically reasonable and necessary when performed as part of a covered breast reconstructive surgery.

3. Mastectomy for Gynecomastia - is considered reconstructive and medically reasonable and necessary if the tissue is primarily breast tissue and not adipose tissue.  All of the following criteria must be met:
   
   
   
   • The patient must have been excluded from, or failed treatment of, any underlying hormone disorder
     
     
   • Reversible medication side effects have been ruled out or the medication cannot be discontinued
     
     
   • In patients where obesity is a documented risk factor, a legitimate medically-based attempt to reduce and maintain weight has failed
     
     
4. Removal of a Breast Implant - placed for reconstructive or cosmetic purposes and/or the revision of a breast implant for reconstructive purposes (post mastectomy) is considered reconstructive and medically reasonable and necessary when performed for one of the following indications:
   
   
   
   • Implant rupture, failure or extrusion
     
     
   • Infection or rejection
     
     
   • Siliconomas or granuloma
     
     
   • Interference with diagnosis of breast cancer
     
     
   • Painful capsular contracture with disfigurement
     

Coverage Limitations

Breast reconstruction for cosmetic reasons (i.e., those services directed at improving appearance and not to improve or restore bodily function) is excluded from coverage.

Performance of any of the services included in this policy for reasons other than to replace absent breast tissue post-tumor removal, trauma, or infection; to correct variation in size of the contralateral unaffected breast; or to correct a congenital defect or abnormality are considered to be cosmetic and are excluded from coverage.

Documentation Requirements

The medical record documentation must support the medical necessity and frequency of this treatment, and include a history and physical pertinent to the indications of this policy.

To support the medical necessity of reduction mammoplasty, the documentation should include the following:

• Breast size/measurements
  
  
• Patient clinical symptoms
  
  
• Conservative therapies attempted and patient response
  
  
• Results of mammogram, ultrasound, and/or MRI as appropriate
  

To support the medical necessity of breast reconstruction of the affected and contralateral unaffected breast following mastectomy, the documentation should include the medically necessary reason for the mastectomy.

To support the medical necessity of mastectomy for gynecomastia, the medical record documentation should include all of the following:

• Breast size/measurements
  
  
• Patient clinical symptoms
  
  
• Conservative therapies attempted and patient response
  
  
• Results of mammogram, ultrasound, and/or MRI as appropriate
  

To support the medical necessity of the removal of a breast implant, the medical record documentation should include the medically necessary reason for the implant removal and the results of any mammogram, ultrasound, and/or MRI as appropriate.

Medical record documentation must be available upon request.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Report the appropriate LT or RT modifier for unilateral breast reconstruction services.

Report the 50 modifier when the same reconstruction procedure is performed bilaterally at the same operative session.

Report procedure code 19340 for immediate breast implant performed at the time of mastopexy, mastectomy or reconstruction.  Report procedure code 19342 for prosthetic reconstruction performed at a separate operative session (later date).

Procedure code 19357 is used to report the global service, postoperative visits and subsequent expansions associated with the insertion of a temporary or permanent tissue expander.  Code 19357 should be reported regardless of whether the procedure is immediate or delayed.

Procedure code 11970 is used to report the removal of a temporary tissue expander and the insertion of a permanent breast prosthesis.  The removal of the temporary expander is not separately reportable.

The breast reconstruction codes 19361 and 19367-19369 are global codes and include all of the following:

• Elevation and transfer of the flap
  
  
• Closure of the donor site
  
  
• Breast contouring
  
  
• Insertion of breast implant or prosthesis, when performed
  

Procedure code 19361 does not include the insertion of the prosthesis.  For insertion of the prosthesis, use code 19340.

Procedure code 19364 includes the above elements and microvascular transfer.  Code 69990 should not be reported in conjunction with code 19364.

TRAM flap codes 19367-19369 also include the following:

• Creation of the breast pocket
  
  
• Elevation of the abdominal flap
  
  
• Muscle dissection
  
  
• Flap transfer
  
  
• Fascial closure (donor site) with or without mesh
  
  
• Abdominal closure including umbilicoplasty
  
  
• Breast contouring
  

Procedure code 19368 is reported for the flap procedures that include an additional artery anastomosed to an artery at the recipient site using microvascular techniques (supercharged).  Code 69990 should not be reported in conjunction with code 19368.

Procedure code 19369 is intended to report a unilateral breast reconstruction using both rectus muscles.

Report procedure codes 11920-11922 based on the size of the nipple and areola created in conjunction with a covered reconstructive service.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Internet On-Line Manual Publication 100-2, Chapter 16, Section 120 is specific to the exclusion of cosmetic surgery.

CMS Internet On-Line Manual Publication 100-3, Chapter 1, Section 140.2 is specific to breast reconstruction following mastectomy.

The following diagnoses support Reduction Mammoplasty (19318):

*NOTE: Diagnosis 611.1 must be reported AND one of the other listed diagnoses

The following diagnoses support Breast Reconstruction (11920-11922, 19316, 19318, 19324, 19325, 19340, 19342, 19350, 19357, 19361, 19364, 19366-19369, 19380, 19396, S2066, S2067, S2068):

The following diagnoses support Mastectomy for Gynecomastia (19300):

The following diagnoses support Removal of a Breast Implant (19328, 19330, 19370, 19371):