Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-84
Topic: Insertion of Tissue Expanders
Effective Date: July 21, 2008
Issued Date: July 21, 2008
Date Last Reviewed: 07/2008

General Policy Guidelines

Indications and Limitations of Coverage

A tissue expander is a device which is surgically implanted to prepare tissue for further surgery such as the insertion of a permanent breast prosthesis, or the subcutaneous repair of other body defects. Once the desired results are achieved, the tissue expander is removed and subsequent reconstructive surgery is performed.

When performed in conjunction with breast surgery, the insertion of a tissue expander is included in the breast reconstructive procedures (19357, 19361).  Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day.  When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

When the insertion of a tissue expander (code 11960) is performed and billed separately on the same day with other reconstructive surgery, multiple surgery guidelines apply.

It is also necessary for a doctor to periodically inject saline solution into the tissue expander in order to achieve the required results. Injections (90799) given during the postoperative period are included in the surgical allowance for the insertion of the expander (11960, 19357 and 19361).  Therefore, separate payment for these injections of saline solution cannot be made.  A participating, preferred, or network provider cannot bill the member separately for the injections.  Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day.  When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

Procedure Codes

11960193571936190799  

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

Aesthetic results and patient satisfaction with immediate breast reconstruction using tissue expansion: a follow-up study, Plastic Reconstructive Surgery, Vol. 99, No. 3, 3/99

A pump for use with tissue expansion in breast reconstruction, Annals R Coll. Surg. Eng., Vol. 80, No. 1, 1/98

Choice of technique for reconstruction, Clinical Plastic Surgery, Vol. 25, No. 2, 4/98

Molecular basis for tissue expansion: clinical implications for the surgeon, Plastic Reconstructive Surgery, Vol. 102, No. 1, 7/98

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Diagnosis Codes

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 Mountain State Blue Cross Blue Shield 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.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.