Breast Reconstructive and Symmetry Surgery Following Mastectomy
DESCRIPTION
Reconstructive surgery is performed to restore normal form or function that is absent as a result of congenital causes, accident or disfigurement from a disease state. Symmetry is defined as correspondence in shape, size, and relative position of parts on opposites of the body.
POLICY
Reconstructive breast surgery, in all stages, on the diseased breast as a result of a mastectomy (not including a lumpectomy as defined by CPT code 19120; located in the Glossary section of this manual) is considered medically necessary.
Surgery on the non-diseased breast, to establish symmetry between the two breasts in the manner chosen by the individual and the physician (e.g. liposuction) is considered medically necessary.
Any devices utilized for these procedures must have FDA approval specific to the indication otherwise its use will be considered investigational.
See also:
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
109th Congress: 1st Session: H. R. 437: (2005, February). Women's health and cancer rights conforming amendments of 2005 (Introduced in House). Retrieved December 18, 2006 from http://thomas.loc.gov.
BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2003). Reconstructive breast surgery/management of breast implants (7.01.22). Retrieved September 30, 2009 from BlueWeb. (10 articles and/or guidelines reviewed)
Centers for Medicare and Medicaid Services. (1998). The Women's Health and Cancer Rights Act. Retrieved December 18, 2006 from http://www.cms.hhs.gov/HealthInsReformforConsume/06_TheWomen'sHealthandCancerRightsAct.asp.
Complete Guide to Medicare Coverage Issues [Computer software]. (2009, July). Breast reconstruction following mastectomy (NCD 140.2, p. 2-66). The Ingenix Complete Guide to Medicare Coverage Issues.
Tennessee Code: Title 56 Insurance: Chapter 7 Policies and Policyholders: Part 25-Mandated Insurer or Plan Options: 56-7-2507. Reconstructive breast surgery. Retrieved December 18, 2006 from http://198.187.128.12/tennessee/lpext.dll?f=templates&fn=fs-main.htm&2.0.
ORIGINAL EFFECTIVE DATE: 7/1/1997
MOST RECENT REVIEW DATE: 11/12/2009
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.
This document has been classified as public information.