Subject:
Post-Mastectomy Reconstructive Breast Surgery
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Post-mastectomy reconstructive breast surgery includes procedures that are performed on the affected breast as well as on the unaffected breast to restore and achieve symmetry between the two breasts.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
1. Reconstructive breast surgery on the affected or diseased breast(s) (e.g., immediate or delayed insertion of breast prosthesis, immediate or delayed breast reconstruction with tissue expander, breast reconstruction with tissue flap procedures including, but not limited to, latissimus dorsi myocutaneous flap, transverse rectus abdominis myocutaneous [TRAM] flap, deep inferior epigastric perforator [DIEP] flap, superficial inferior epigastric perforator [SIEP] flap, inferior or superior gluteal free flap, inferior or superior gluteal artery perforator [IGAP or SGAP] flap and thoracodorsal artery perforator [TDAP]) flap, and nipple/areola reconstruction, etc. is considered medically necessary following mastectomy.
(Informational Note: Nipple/areola reconstruction includes nipple/areolar tattooing is considered medically necessary following mastectomy.)
2. Breast surgery on the unaffected or healthy breast is also considered medically necessary to restore and achieve symmetry between the two breasts.
Medicare Coverage:
Per National Coverage Determination (NCD) 140.2, breast reconstruction surgery following removal of a breast for any medical reason is a covered service. Please refer to NCD 140.2 Breast Reconstruction following Mastectomy. Available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx. In addition, Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has determined that removal of breast implants is covered when the LCD criteria are met. For eligibility and coverage refer to Novitas Solutions Inc, LCD L35090 Cosmetic and Reconstructive Surgery. Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/LcdSearch?_afrLoop=90769712476969#!%40%40%3F_afrLoop%3D90769712476969%26centerWidth%3D100%2525%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3D63y7eftob_46.
Medicaid Coverage:
FIDE-SNP
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Post-Mastectomy Reconstructive Breast Surgery
Breast Surgery, Reconstructive
Reconstructive Breast Surgery, Post-Mastectomy
Symmetry, Post-Mastectomy Breast Surgery for
References:
1. New Jersey State Mandate (P.L. 1997, Chapter 75 - S1783) effective July 16, 1997, requiring health insurance coverage for reconstructive breast surgery to restore and achieve symmetry following mastectomy on one breast or both breasts.
2. ECRI Institute. Custom Hotline Response: DIEP Flap and TRAM Flap for Breast Reconstruction. Updated: 10/14/2004.
3. American Cancer Society. Breast Reconstruction after Mastectomy. Revised: 09/06/2007. Available at: http://www.cancer.org/docroot/CRI/content/CRI_2_6X_Breast_Reconstruction_After_Mastectomy_5.asp (last accessed 02/05/08)
4. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD) for Breast Reconstruction Following Mastectomy (140.2). Effective date: 01/01/97. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=64&ncdver=1&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=New+Jersey&KeyWord=breast+reconstruction&KeyWordLookUp=Title&KeyWordSearchType=And&ncd_id=140.2&ncd_version=1&basket=ncd%25253A140%25252E2%25253A1%25253ABreast+Reconstruction+Following+Mastectomy&bc=gAAAABAAAAAAAA%3d%3d& (last accessed 11/12/2013).
4. Breast Reconstruction, Perforator Flap. emedicine. Last updated: February 1, 2007. Available at: http://www.emedicine.com/plastic/topic545.htm (last accessed 11/12/2013).
5. Rolph R, Mehta S, Farhadi J. Breast reconstruction: options post-mastectomy. Br J Hosp Med (Lond) 2016 Jun;77(6):334-42.
6. Quinn TT, Miller GS, Rostek M, et al. Prosthetic breast reconstruction: indications and update. Gland Surg 2016 Apr;5(2):174-86.
7. van Huizum MA, Hage JJ, Rutgers EJ, et al. Immediate breast reconstruction with a myocutaneous latissimus dorsi flap and implant following skin-sparing salvage mastectomy after irradiation as part of breast-conserving therapy. J Plast Reconstr Aesthet Surg 2016 Feb 11. [Epub ahead of print]
8. UpToDate. Overview of breast reconstruction. Literature review current through June 2016. Topic last updated October 9, 2015.
9. UpToDate. Options for flap based breast reconstruction. Literature review current through July 2016. Topic last updated April 15, 2016.
10. Nahabedian M. Overview of breast reconstruction. In: UpToDate, Chagpar AB, Butler CE, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on July 7, 2017.)
11. Nahabedian M. Overview of breast reconstruction. In: UpToDate, Chagpar AB, Butler CE, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on May 17, 2018)
12. Nahabedian M., Gutowski KA. Complications of Reconstructive and Aesthetic Breast Surgery. In: UpToDate, Butler CE, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on May 17, 2018)
13. Nahabedian M. Options for Flap-based breast reconstruction. In: UpToDate, Chagpar AB, Butler CE, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on May 17, 2018)
14. Nahabedian M. Overview of breast reconstruction. In: UpToDate, Chagpar AB, Butler CE, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on June 17, 2019)
15. Nahabedian M., Gutowski KA. Complications of reconstructive and aesthetic breast surgery. In: UpToDate, Butler CE, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on June 17, 2019)
16. Nahabedian M. Options for flap-based breast reconstruction. In: UpToDate, Chagpar AB, Butler CE, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on June 17, 2019)
17. Nahabedian M. Implant-based breast reconstruction and augmentation. In: UpToDate, Butler CE, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on June 17, 2019)
18. Nahabedian M. Overview of breast reconstruction. In: UpToDate, Chagpar AB, Butler CE, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on July 1, 2020)
19. Nahabedian M., Gutowski KA. Complications of reconstructive and aesthetic breast surgery. In: UpToDate, Butler CE, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on July 1, 2020)
20. Nahabedian M. Options for flap-based breast reconstruction. In: UpToDate, Chagpar AB, Butler CE, Collins KA (Eds), UpToDate, Waltham, MA.(Accessed on July 1, 2020)
21. Nahabedian M. Implant-based breast reconstruction and augmentation. In: UpToDate, Butler CE, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on July 1, 2020)
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
11920
11921
11922
19316
19318
19324
19325
19328
19330
19340
19342
19350
19355
19357
19361
19364
19366
19367
19368
19369
19370
19371
19380
19396
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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