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HealthPartners

Coverage criteria policies

Breast surgery

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

This policy addresses

  • reconstructive breast surgery following mastectomy/ lumpectomy
  • reconstructive breast surgery for Poland Syndrome
  • breast implant removal.

For other breast related procedures, please see Related Content at right for links to coverage criteria.

Prior authorization is not required for:

  • Breast reconstruction following a covered mastectomy or lumpectomy (including surgery for asymmetry)

Prior authorization is required for:

  • Surgery for Poland syndrome
  • Breast implant removal

Coverage

Breast surgery is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

Breast Surgery:
  1. Breast reconstruction following a covered mastectomy or lumpectomy, including autologous fat injection/ transfer, insertion of tissue expanders, breast implants and nipple reconstruction, which includes tattooing, of the affected breast.
  2. Acellular dermal matrix products are covered for post mastectomy breast reconstruction.
  3. Tram flap or similar type of reconstructive breast surgery following a mastectomy.
  4. Mastopexy, reduction, and/ or augmentation for breast asymmetry on the contralateral (unaffected) breast following a covered mastectomy or lumpectomy.
  5. Breast reconstruction or augmentation for Poland syndrome as defined below. Medical records must include documentation to support the diagnosis of Poland syndrome.
  6. Replacement implants are covered when the original implants, which were placed for a covered condition (i.e., diagnosis of breast cancer), have been removed (see Implant Removal criteria below).

Indications that are not covered

Breast Surgery:
  1. Breast surgery for any reason other than the covered conditions described above by this policy (or by our other breast health related policies), is considered cosmetic and not medically necessary including but not limited to:
    1. Correction of involution (shrinkage) or ptosis (drooping)
    2. Replacement of implants for reasons other than for a covered condition (described above)
    3. Additional reconstructive surgeries beyond an initial covered reconstructive surgery unless:
      1. The initial reconstructive surgery is being done as a staged procedure; or
      2. The initial reconstruction resulted in a medically adverse or unintended outcome.
    4. Breast reconstruction or augmentation for asymmetrical / hypoplastic / aplastic breasts that are not diagnosed as Poland syndrome.
    5. Breast Lift (mastopexy)
    6. Surgery to remove extra axillary breast tissue
    7. Surgery to remove supernumerary nipples
    8. Surgery to correct tuberous breast deformity
    9. Surgery to correct inverted nipples

Indications that are covered

Implant Removal:
  1. Removal of implants is covered when the original implants were placed for a covered condition.
  2. Removal of non-covered implants (such as implants placed for cosmetic reasons) is covered only when painful capsular contracture is present.
  3. Removal of silicone implants is covered when there is documented evidence of leaking causing medical complications.

Indications that are not covered

Implant Removal:
  1. Removal of implants is not covered for cosmetic reasons.
  2. Screening using MRI, ultrasound, etc. to determine implant rupture or leaking in asymptomatic individuals is not covered as it is not medically necessary.
  3. Removal of non-covered implants is not covered, except as described above.

Definitions

Acellular dermal matrix (ADM) is used for soft tissue replacement for breast reconstruction after mastectomy. It provides biologic scaffolding that assists in formation of connective tissue as it stabilizes the position of the pectoralis major muscle in order to prevent upward migration of the muscle. Products include AlloDerm, AlloMax, DermACELL, DermaMatrix, FlexHD, Strattice and SeriSurgical Scaffold

Aplasia is a lack of development of an organ or tissue or of the cellular products from an organ or tissue.

Autologous fat transfer (also called autologous fat grafting or fat injection) involves the removal and relocation of the patient’s own body fat (usually from the abdomen, buttocks or thighs). Liposuction is used to remove the fat, which is then processed and injected into the breast.

Breast implant is a bag or pouch filled with a solution and placed under the skin to rebuild the breast after mastectomy or to enhance the size of a breast in cosmetic breast augmentation surgery.

Breast reconstruction is a procedure in which an expander or an implant or tissue from other parts of the body is used to rebuild the breast.

Hypoplasia is the incomplete development or under development of an organ or tissue.

Mastopexy, also known as a breast lift, is a procedure which raises the breasts by removing excess skin and tightening the surrounding tissue to reshape and support the new breast contour.

Poland syndrome is a rare disease that causes chest wall deformity. People with Poland Syndrome are missing at least part of the muscle from one side of their chest, sometimes missing a rib(s), and may have only one fully developed breast/nipple.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

CPT Code

Description

19120

Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions

19316

Mastopexy

19318

Reduction mammaplasty

19324

Mammaplasty, audmentation: without prosthetic implant

19325

Mammaplasty, audmentation: 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 in 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 abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site

19368

Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; with microvascular anastomosis (supercharging)

19369

Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site

19370

Incision of capsule surrounding breast with freeing of scar tissue, open procedure

19371

Periprosthetic capsulectomy, breast

19380

Revision of reconstructed breast

19396

Preparation of moulage for custom breast implant

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

ICD-10 Code

Description

N65.0

Deformity of reconstructed breast

N65.1

Disproportion of reconstructed breast

Q79.8

Poland Syndrome

Q83.3

Accessory nipple

Q83.8

Other congenital malformations of breast

T85.41XA-T85.41XS

Breakdown(mechanical) of breast prosthesis and implant

T85.42XA-T85.42XS

Displacement of breast prosthesis and implant

T85.43XA-T85.43XS

Leakage of breast prosthesis and implant

T85.44XA-T85.44XS

Capsular contracture of breast implant

T85.49XA-T85.49XS

Other Mechanical complication of breast prosthesis and implant

Z42.1

Encounter for breast reconstruction following mastectomy

Z45.811-Z45.819

Encounter for adjustment or removal of breast implant.

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. American Society of Plastic Surgeons. (2015). Post-mastectomy fat graft/ fat transfer ASPS guiding principles. Available from www.plasticsurgery.org
  2. Cher, D. J., Conwell, J. A., Mandel, J. S. (2001). MRI for detecting silicone breast implant rupture: meta-analysis and implications. Annals of Plastic Surgery, 47(4), 367-380.
  3. Nahabedian, M. Complications of reconstructive and aesthetic breast surgery. In: UpToDate, Butler, C. E., & Collins, K. A. (Eds), UpToDate, Waltham, MA. (Accessed on February 3, 2017.)
  4. Women's Health and Cancer Rights Act of 1998, 9 U.S.C. §§901-903 (2012).

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Policy activity

  • 07/01/1995 - Date of origin
  • 07/01/2017 - Effective date
Review date
  • 02/2017
Revision date
  • 03/21/2017

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