BlueCross BlueShield of Tennessee Medical Policy Manual

Breast Augmentation / Mammaplasty (Non-Cancerous)

DESCRIPTION

Breast augmentation / mammaplasty is a procedure used to correct 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 unilaterally or bilaterally and may be congenital or acquired.  Some of the more common deformities indicated for breast reconstruction surgery includes Poland’s Syndrome and tuberous breast(s).

POLICY

See also:

MEDICAL APPROPRIATENESS

IMPORTANT REMINDERS

ADDITIONAL INFORMATION

TN State Mandate addressing reconstructive breast surgery applies to services rendered following mastectomy and does not apply to this policy.

SOURCES

American Academy of Plastic Surgeons. (2004). Non-cancer related breast reconstruction. Retrieved February 28, 2014 from http://www.plasticsurgery.org/for-medical-professionals/quality-and-health-policy/evidence-based-medicine-guidelines.html.

Brault, N., Stivala, A., Guillier, D., Moris, V., Revol, M., Francois, C., & Cristofari, S. (2017). Correction of tuberous breast deformity: a retrospective study comparing lipofilling versus breast implant augmentation. Journal of Plastic, Reconstruction and Aesthetic Surgery, 70 (5), 585-595. Abstract retrieved April 20, 2017 from PubMed database.

Klinger, M., Caviggioli, F.,Giannasi, S., Bandi, V., Banzatti, B., Veronesi, A. (2016). The prevalence of tuberous/constricted breast deformity in population and in breast augmentation and reduction mammaplasty patients. Aesthetic Plastic Surgery. 2016 June 6. [Epub ahead of print] Abstract retrieved July 6, 2016 from PubMed database.

Palmetto Government Benefit Administrators. (2018, February). LCD for cosmetic and reconstructive surgery (L33428). Retrieved March 12, 2018 from www.cms.gov.

Winocour, S., & Lemaine, V. (2013). Hypoplastic breast anomalies in the female adolescent breast. Seminars in Plastic Surgery, 27 (1), 42-48. (Level 5 evidence)

ORIGINAL EFFECTIVE DATE:  1/11/1983

MOST RECENT REVIEW DATE:  4/12/2018

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.