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Section: Surgery
Number: S-129
Topic: Mastectomy and Reconstructive Surgery
Effective Date: January 1, 2010
Issued Date: January 17, 2011
Date Last Reviewed:

General Policy Guidelines

Indications and Limitations of Coverage

Mastectomy

Medically necessary services that are appropriate for the symptoms and diagnosis, or treatment of the member's condition, illness, or injury are contractually covered. The services must also be in accordance with current standards of good medical care.

Mastectomy (19301-19307) is the removal of all or part of a breast. Mastectomies are most typically performed as a treatment for cancer. However, mastectomies are also performed for the treatment of benign disease.

Mastectomy for Fibrocystic Breasts

Although fibrocystic breasts may not be considered a disease state, it is considered a condition or a "disorder." There may be no symptoms, but for those women who do have symptoms, they range from mild to severe. Mastectomy is not the appropriate treatment for fibrocystic breasts in all cases. However, mastectomy for fibrocystic breasts may be indicated 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. However, the presence of nipple discharge is rarely present in a fibrocystic breast.

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.

The type of mastectomy (subcutaneous, partial, modified, or radical) and the timing of the surgery varies for each patient and is determined by the surgeon.

NOTE:
See Medical Policy Bulletin S-163 for guidelines on prophylactic mastectomy.

Reconstructive Surgery

Reconstructive breast surgery is defined as those surgical procedures designed to restore the normal appearance of a breast following a mastectomy. Reconstructive surgery includes all surgery on the affected breast and surgery on the contralateral normal breast to re-establish symmetry between the two breasts or to alleviate functional impairment caused by the mastectomy.

Symmetry is defined as approximate equality in size and shape of the nondiseased breast with the diseased breast after definitive reconstructive surgery on the diseased or nondiseased breast has been performed.

The most common type of reconstructive surgery following mastectomy is the insertion of a silicone gel-filled or saline-filled breast implant. The implant can be inserted immediately at the time of mastectomy (19340), or sometime afterward in conjunction with the previous use of a tissue expander (19342, 19357).

Other types of reconstruction on the diseased breast include, but are not limited to:

  • Nipple/areola reconstruction (19350)
  • Nipple tattooing (19499)
  • Transverse rectus abdominis myocutaneous flap (TRAM) (19367-19369, S2066, S2067, S2068), latissimus dorsi flap (19361), or free flap (19364)
  • Preparation of moulage for custom breast implant (19396) 
The following procedures performed on the contralateral normal breast to provide symmetry with the reconstructed breast are also considered reconstructive procedures: (Note: This is not an all inclusive list.)
  • Augmentation mammoplasty (19324, 19325)
  • Reduction mammoplasty (19318)
  • Mastopexy (19316)

    Note:
    See Medical Policy Bulletin S-28 for additional guidelines on cosmetic vs. reconstructive breast surgery. Also see Medical Policy Bulletin S-76 for guidelines on the removal and reinsertion of breast implants.

Prosthetics are defined as the use of initial and subsequent artificial devices to replace the removed breast or portions of the breast.

Effective February 1, 1998, the following prosthetics are covered:

  • Breast prosthesis, mastectomy bra (L8000)
  • Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral (L8001)
  • Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral (L8002)
  • Breast prosthesis, mastectomy sleeve (L8010)
  • Breast Prosthesis, mastectomy form (L8020)
  • Breast prosthesis, silicone or equal (L8030)
  • Breast prosthesis, not otherwise specified (L8039)
  • Adhesive skin support attachment for use with external breast prosthesis, each (A4280)
  • External breast prosthesis garment, with mastectomy form, post mastectomy (L8015)
  • Custom breast prosthesis, post mastectomy, molded to patient model (L8035)
  • Implantable breast prosthesis, silicone or equal (L8600)
  • Camisole, post-mastectomy (S8460)
  • Breast prothesis, silicone or equal, with integral adhesive (L8031)
  • Nipple prothesis, reusable, any type, each (L8032)

    NOTE:
    When the implantable breast prosthesis (L8600) is provided by the hospital, the charge should be billed as a hospital expense. When the physician incurs the cost of the implant, the charge should be billed as a professional expense.

    Charges for an implantable breast prosthesis should be denied as cosmetic when the implant is provided in conjunction with a cosmetic augmentation mammoplasty (19324-19325). (See cosmetic augmentation mammoplasty.)

Coverage for the home health visit should be billed as a hospital expense.

Coverage for the services are subject to any copayments, coinsurances or deductibles, and all other terms and conditions, set forth in the patient's contract.


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.

Procedure Codes

193011930219303193041930519306
193071931619318193241932519340
193421935019357193611936419367
19368193691939619499A4280L8000
L8001L8002L8010L8015L8020L8030
L8031L8032L8035L8039L8600S2066
S2067S2068S8460   

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits, or a contract.  Benefits are determined by the Federal Employee Program.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

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Table Attachment

Text Attachment

Procedure Code Attachments

Diagnosis Codes

610.1   

Glossary





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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Highmark West Virginia plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Highmark West Virginia retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark West Virginia. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.



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