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) 

• 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.

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 prosthesis, silicone or equal, with integral adhesive (L8031)
• Nipple prosthesis, 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 these services are subject to any copayments, coinsurances or deductibles, and all other terms and conditions, set forth in the patient's contract.

Place of Service: Inpatient/Outpatient

When performed for non-cancer diagnoses or independent of the mastectomy or the breast reconstruction flap, nipple/areola reconstruction, nipple tattooing, preparation of moulage for custom breast implants, augmentation mammoplasty, reduction mammoplasty, and mastopexy are typically outpatient procedures which are only eligible for coverage as inpatient procedures in special circumstances including, but no limited to, current therapeutic anticoagulation therapy or when performed in conjunction with a service typically performed in the inpatient setting.

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.

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.

InterQual® Level of Care Criteria 2010. Acute Care Adult. McKesson Health Solutions, LLC.