CAM 079

Breast Surgical Procedures/Prosthesis

Category:Surgery   Last Reviewed:September 2019
Department(s):Medical Affairs   Next Review:September 2020
Original Date:October 1977    

Description:
A mastectomy is a surgical procedure designed to remove all or part of the breast.  It is typically performed for the treatment of breast cancer, breast disease or gynecomastia.  Reconstructive surgery following a mastectomy is typically a covered benefit.  Please see specific contract verbiage for exclusions, limitations and/or maximums.

PRIOR AUTHORIZATION MUST BE OBTAINED FOR MEDICAL NECESSITY IN ORDER TO BE CONSIDERED FOR REIMBURSEMENT OF THE PLAN BENEFITS, UNLESS OTHERWISE INDICATED BY THE SPECIFIC CONTRACT VERBIAGE. 

Reconstructive surgery performed following a mastectomy is a covered benefit.  The procedure typically includes the reconstruction of the mastectomy site, creation of a new breast mound, along with the creation of a new nipple/areolar complex. It may also include reconstruction of the non-diseased breast to achieve symmetry.  Such procedures may include, but are not limited to, DIEP, GIEP or the SGAP procedure. Nipple tattooing is considered to be an integral part of the nipple/areolar reconstructive procedure and not reimbursed as a separate service but rather as part of the whole procedure. 

Reconstructive breast surgery is a covered benefit when the following criteria are met: 

  • The procedure follows mastectomy.  It may be performed at the time of the mastectomy or post-operatively, as long as the mastectomy was MEDICALLY NECESSARY (i.e., breast cancer or benign disease not responsive to conservative measures).  Please see specific contract verbiage for exclusions or limitations.
  • Augmentation mammaplasty, reduction mammaplasty and/or mastopexy may be considered a covered benefit for the non-diseased breast following a MEDICALLY NECESSARY mastectomy for the achievement of breast symmetry. 

**All reconstructive surgery, including. but not limited to, mastectomy, augmentation mammaplasty, reduction mammaplasty and/or mastopexy must have prior authorization.** 

Insertion and Removal of Breast Implants
Breast implants are prostheses used for post mastectomy reconstruction or used for the enlargement of breasts that are typically cosmetic in nature.  Breast implants used solely for cosmetic purposes are not a covered benefit.
 

A breast prosthesis can be used either internally or externally.  For internal usage, the breast implant is placed into the breast area once the natural breast tissue has been removed.  External usage is accomplished by wearing a specially fitted brassiere. One external prosthesis per year may be allowed without review; however, more than one external prosthesis per year must be reviewed for medical necessity.  Up to four (4) prosthetic bras per year will be allowed without individual consideration and review. Please review specific contract verbiage for exclusions, limitations and/or maximums. 

Coverage Criteria for Insertion and Removal of Breast Implants 

  • Insertion of a breast implant is a covered benefit when performed as part of post-surgical mastectomy reconstruction. Removal of breast implants is a covered benefit when it is medically necessary due to complications that are related to a covered indication. 

Non-Coverage Criteria for Insertion and Removal of Breast Implants

  • Breast implants are not a covered benefit when used primarily for cosmetic purposes.
  • Removal of breast implants is not a covered benefit when the patient is asymptomatic (i.e., pain, etc.).
  • Removal of breast implants is not covered when the original implant was performed primarily for cosmetic purposes or for other non-covered indications in those contracts that specifically exclude complications of a non-covered service.

PRIOR AUTHORIZATION MUST BE OBTAINED FOR MEDICAL NECESSITY IN ORDER TO BE CONSIDERED FOR REIMBURSEMENT OF THE PLAN OF BENEFITS, UNLESS OTHERWISE INDICATED BY THE SPECIFIC CONTRACT.

Scientific Background and Reference Sources:

  1. The Blue Cross and Blue Shield Association, Reduction Mammoplasty; Original Policy Date: 12/95, Review Date: 4/03.
  2. The Blue Cross and Blue Shield Association: Prophylactic Mastectomy;  12/99  Original Policy: Reviewed 2/03.
  3. The Blue Cross and Blue Shield Association: Mastectomy for Gynecomastia; Original policy issued by the Blue Cross and Blue Association: Original Policy Date: 12/95, Review Date: 2/03.
  4. The Blue Cross and Blue Shield Association:  Reconstructive Breast Surgery/Management of Breast Implants  11/97; Original policy issued by the Blue Cross and Blue Shield Association; Original Policy Date:  11/97,  Review Date:  2/03.
  5. Women's Health and Cancer Rights Act of 1998.
  6. South Carolina Senate 13.19 Proposed Legislation (Omnibus Appropriations Bill); 10/98.
  7. The New England Journal of Medicine:  Complications Leading to Surgery after Breast Implants; 03/97.
  8. Plastic Information Services, Breast Reconstruction; 06/99.
  9. Methodist Health Care Systems, Breast Care-Post Mastectomy Prosthesis.  

Coding Section   

Codes Number Description
CPT 00402

Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; reconstructive procedures on breast (e.g., reduction or augmentation mammoplasty, muscle flaps)

  00404

Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified radical procedures on breast

  00406 Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified radical procedures on breast with internal mammary node dissection
  11920

Tattooing, Intradermal Introduction of Insoluble Opaque Pigments to Correct Color Defects of Skin, including Micropigmentation; 6.0² cm or less

  11921

Tattooing, Intradermal Introduction of Insoluble Opaque Pigments to Correct Color Defects of Skin, including Micropigmentation, 6.1 to 20.0²cm

  11922

Tattooing, Intradermal Introduction of Insoluble Opaque Pigments to Correct Color Defects of Skin, including Micropigmentation; each

  11970 Replacement of tissue expander with permanent prosthesis
  11971 Removal of tissue expander(s) without insertion of prosthesis
  15271

Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area

  15272

Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure)

  15777

Implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement (i.e., breast, trunk) (list separately in addition to code for primary procedure)

  15877

Suction assisted lipectomy; trunk

  17999

Unlisted procedure, skin, mucous membrane and subcutaneous tissue

  19316

Mastopexy

  19318  Reduction mammaplasty
  19324

Mammaplasty, Augmentation; Without Prosthetic Implant

  19325

Mammaplasty, Augmentation; With Prosthetic Implant 

  19328 Removal of intact mammary implant 
  19330 Removal of mammary implant material 
  19340

Immediate Insertion of Breast Prosthesis Following Mastopexy, Mastectomy or Reconstruction 

  19342

Delayed Insertion of Breast Prosthesis Following Mastopexy, Mastectomy or In Reconstruction

  19350

Nipple/Areola Reconstruction 

  19355  Correction of inverted nipples 
  19357 

Breast Reconstruction, Immediate or Delayed, With Tissue Expander, Including Subsequent Expansion 

  19361 

Breast Reconstruction with Latissimus Dorsi Flap without Prosthetic Implant 

  19364 

Breast Reconstruction with Free Flap 

  19366 

Breast Reconstruction with Other Technique 

  19367 

Breast Reconstruction with Transverse Rectus Abdomins Myocutaneous Flap (Tram), Single Pedicle, Including Closure of Donor Site 

  19368 

Breast Reconstruction with Transverse Rectus Abdomins Myocutaneous Flap (Tram), Single Pedicle, Including Closure of Donor Site; With Microvascular Anastomosis (Supercharging) 

  19369 

Breast Reconstruction with Transverse Rectus Abdomins Myocutaneous Flap (Tram), Double Pedicle, Including Closure of Donor Site 

  19370  Open periprosthetic capsulectomy, breast 
  19371  Periprosthetic capsulectomy, breast 
  19380 

Revision of Reconstructed Breast 

  19396 

Preparation of Moulage for Custom Breast Implant 

  19499  Unlisted procedure, breast 
ICD-9 Diagnosis     174-174.9

Malignant Neoplasm of Female Breast 

  175-175.9 

Malignant Neoplasm of Male Breast  

  198.81 

Secondary Malignant Neoplasm of Other Specified Sites, Breast 

  233 

Carcinoma in situ of breast and genitourinary system, Breast 

  234.8  Carcinoma in situ of other specified sites 
  234.9  Carcinoma in situ, site unspecified 
  V10.3 

Personal History of Malignant Neoplasm, Breast 

  V16.3  Family history of malignant neoplasm of breast 
  V43.82  Breast replacement 
  V45.71 

Acquired Absence of Breast 

  V50.41  Prophylactic breast removal 
  V51.0  Encounter for breast reconstruction following mastectomy 
  V52.4 Fitting and adjustment of breast  prosthesis and implant
HCPCS  C1789  Prosthesis, breast (implantable) 
  L8600  Implantable breast prosthesis, silicone or equal 
  S2066  Breast reconstruction with gluteal artery perforator (gap) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral 
  S2067  Breast reconstruction of a single breast with "stacked" deep inferior epigastric perforator (diep) flap(s) and/or gluteal artery perforator (gap) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateral 
  S2068  Breast reconstruction with deep inferior epigastric perforator (diep) flap or superficial inferior epigastric artery (siea) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral 
ICD-10-CM (effective 10/01/15) 

C50.01-C50.119

Malignant neoplasm of nipple and areola, unspecified female breast

 

C50.2-C50.219 

Malignant neoplasm of upper-inner quadrant of breast, unspecified female breast 

 

C50.3-C50.319 

Malignant neoplasm of lower-inner quadrant of breast, unspecified female breast 

 

C50.4-C50.419 

Malignant neoplasm of upper-outer quadrant of breast, unspecified female breast 

 

C50.5-C50.519 

Malignant neoplasm of lower-outer quadrant of breast, unspecified female breast 

 

C50.6-C50.619 

Malignant neoplasm of axillary tail of breast, unspecified female breast 

 

C50.8-C50.819 

Malignant neoplasm of overlapping sites of breast, unspecified female breast 

 

C50.9-C50.919 

Malignant neoplasm of breast of unspecified site, unspecified female breast 

  C50.029  Malignant neoplasm of nipple and areola, unspecified male breast 
  C50.929  Malignant neoplasm of unspecified site of unspecified male breast 
  C79.81  Secondary malignant neoplasm of breast 
  D05.90  Unspecified type of carcinoma in situ of unspecified breast 
  D09.3  Carcinoma in situ of thyroid and other endocrine glands 
  D09.8  Carcinoma in situ of other specified sites 
  D09.9  Carcinoma in situ, unspecified 
  Z85.3  Personal history of malignant neoplasm of breast 
  Z80.3  Family history of malignant neoplasm of breast 
  Z98.82  Breast implant status 
  Z90.10  Acquired absence of unspecified breast and nipple 
  Z90.11  Acquired absence of right breast and nipple  
  Z90.12 Acquired absence of left breast and nipple  
  Z90.13  Acquired absence of bilateral breasts and nipples  
  Z40.01  Encounter for prophylactic removal of breast 
  Z42.1  Encounter for breast reconstruction following mastectomy 
  Z44.30  Encounter for fitting and adjustment of external breast prosthesis, unspecified breast 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

09/01/2019 

Annual review, no change to policy intent. 

09/05/2018 

Annual review, no change to policy intent. 

09/07/2017 

Annual review, no change to policy intent. 

09/01/2016 

Annual review, no change to policy intent. Updating coding. 

09/17/2015

Annual review, no change to policy intent. Adding coding.

09/11/2014

Annual review. No changes made to policy.


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