Breast Augmentation / Mammaplasty (Non-Cancerous)
DESCRIPTION
Breast augmentation / mammaplasty is used to correct female breast hypoplasia or agenesis. Hypoplasia is defined as the underdevelopment or incomplete development of a tissue or organ. Agenesis is defined as lack of development. These conditions can occur unilateral or bilateral and result from heredity or as a developmental condition. A small degree of asymmetry between the breasts is normal.
Breast augmentation/mammaplasty involves implantation of a synthetic prosthetic device. There are three types of implants, saline-filled breast implants, silicone gel-filled breast implants and alternative breast implants. The alternative breast implant typically has a silicone rubber shell with filler other than saline or silicone gel.
POLICY
Breast augmentation/mammaplasty, on the affected non-cancerous breast for unilateral agenesis or marked unilateral hypoplasia, in order to create symmetry is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Breast augmentation for non-cancerous bilateral agenesis or marked hypoplasia is considered cosmetic.
Surgery to correct inverted nipples is not considered breast augmentation, and is considered cosmetic.
See also:
MEDICAL APPROPRIATENESS
Breast augmentation/mammaplasty, on the affected non-cancerous breast for unilateral agenesis or marked unilateral hypoplasia, in order to create symmetry is considered medically appropriate if ALL of the following criteria are met:
Photographs must provide evidence of significant congenital or acquired deformities (color photos preferred)
Photographs must provide evidence of asymmetry and deformities beyond normal variations (color photos preferred)
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member’s health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2003). Reconstructive breast surgery/management of breast implants (7.01.22). Retrieved September 30, 2008 from BlueWeb. (10 articles and/or guidelines reviewed)
Children’s Oncology Group. (2008, October). Long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers. Retrieved August 26, 2011 from http://www.guideline.gov/content.aspx?id=15470&search=breast+reconstruction.
Complete Guide to Medicare Coverage Issues [Computer software]. (2011, April). Breast reconstruction following mastectomy (ND140.2, p. 2-69). Ingenix.
Kliegman, R. II. & Nelson, W. E. (Eds). (2011). Nelson textbook of pediatrics (19th ed.) Philadelphia: Elsevier Saunders.
Tennessee Code: Title 56 Insurance: Chapter 7 Policies and Policyholders: Part 25 Mandated Insurer or Plan Options: 56-7-2507. Reconstructive breast surgery. Retrieved October 2, 2008 from http://www.legislature.state.tn.us/sitemap.htm.
U. S. Food and Drug Administration. (2011, June). Center for Devices and Radiological Health. FDA update on the safety of silicone gel-filled breast implants. Retrieved August 26, 2011 from http://www.fda.gov/downloads/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/UCM260090.pdf.
ORIGINAL EFFECTIVE DATE: 1/11/1983
MOST RECENT REVIEW DATE: 10/13/2011
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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