Breast Reconstruction Following Mastectomy or Lumpectomy
[For the list of services and procedures that need preauthorization, please refer to www.mcs.pr Go to“Comunicados a Proveedores”, and click “Cartas Circulares”.]
Medical Policy: MP-SU-02-10
Original Effective Date: March 25, 2010
Reviewed:
Revised: March 19, 2013
This policy applies to products subscribed by the following corporations, MCS Life Insurance Company (Commercial), and MCS Advantage, Inc. (Classicare) and Medical Card System, Inc., provider’s contract; unless specific contract limitations, exclusions or exceptions apply. Please refer to the member’s benefit certification language for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply subject to the aforementioned exceptions.
DESCRIPTION
For the purposes of this medical policy, reconstructive breast surgery refers to surgery performed to individuals who underwent mastectomy or lumpectomy to correct or repair abnormal structures of the breast.
Breast reconstruction is often considered after mastectomy to correct deformity or reestablish symmetry caused by previous surgery and/or the effects of therapeutic treatments.
Reconstruction procedures may involve multiple techniques and stages to recreate the breast mound using prosthetic implants, tissue flaps, or autologous tissue transfers, as well as nipple/areola reconstruction or tattooing and breast reduction. These procedures can be performed immediately after a mastectomy (one stage breast reconstruction), or be delayed for weeks or years until a patient undergoes radiation, chemotherapy, or determines whether they want breast reconstruction (two-stage reconstruction).
COVERAGE
Benefits may vary between groups and contracts. Please refer to the appropriate member certificate and subscriber agreement contract for applicable diagnostic imaging, DME, laboratory, machine tests, benefits, and coverage.
INDICATIONS
Note: Breast Reconstruction services of the affected and the contra-lateral unaffected breast following a mastectomy or lumpectomy is considered medically necessary for all stages of reconstruction of the breast on which the mastectomy has been performed; when surgery and reconstruction of the other breast is to produce a symmetrical appearance; and for prostheses and physical complications of all stages of mastectomy, including lymphedema.
I. Medical Card System, Inc., (MCS) will consider medically necessary Breast Reconstruction services of the affected breast after a mastectomy or lumpectomy performed for any medical reason.
Medically necessary procedures include:
a. Tissue/muscle reconstruction procedures (flaps)
transverse rectus abdominus myocutaneous flap,
latissimus dorsi (LD) myocutaneous flap,
deep inferior epigastric perforator (DIEP) flap,
superficial inferior epigastric perforator (SIEP)flap,
superior or inferior gluteal free flap
Ruben’s flap b. Capsulotomyi
c. Capsulectomyii
d. Implantation of tissue expander
e. Implantation of U.S. FDA approved internal breast prosthesis f. Areolar and nipple reconstruction
g. Areolar and nipple tattooing h. Reconstructive surgical revisions
i. Removal or revision of a breast implant is considered medically necessary when it is removed for one of the following reasons:
Mechanical complication of breast prosthesis; including rupture or failed implant, implant extrusion;
Infection or inflammatory reaction due to a breast prosthesis; including infected breast implant, or rejection of breast implants;
Other complication of internal breast implant; including siliconoma, granuloma, interference with diagnosis of breast cancer, painful capsular contracture with disfigurement.
II. Medical Card system, Inc., (MCS) will consider medically necessary Breast Reconstruction services of the unaffected/contra-lateral breast, in order to produce a symmetrical appearance after a mastectomy or lumpectomy performed for any medical reason. Medically necessary procedures include:
a. Breast reduction by mammoplasty or mastopexyiii b. Augmentation mammoplasty
c. Augmentation with implantation of FDA approved internal breast prosthesis when the unaffected breast is smaller than the smallest available internal prosthesis
d. Areolar and nipple reconstruction e. Areolar and nipple tattooing
f. Reconstructive surgery revisions to produce a symmetrical appearance
g. Breast implant removal and subsequent reimplantation when performed to produce a symmetrical appearance
h. Capsulotomy j. Capsulectomy
III. Medical Card System, Inc., (MCS) will consider medically necessary the following products when use in association with a covered medically necessary breast reconstruction procedure:
a. AlloDerm®
b. NeoForm™ Dermis
IV. Medical Card System, Inc., (MCS) considers the following products and procedures to be:
Experimental, Investigational or Unproven:
a. DermaMatrix® Acellular Dermis b. Permacol®
c. Radiesse®
d. Strattice™ reconstructive tissue matrix
e. Breast reconstruction after a medically necessary mastectomy when not associated with mastectomy or lumpectomy preformed for breast cancer.
f. Autologous fat transplant used in association with a breast reconstruction.
CODING INFORMATION
CPT® Codes (List may not be all inclusive)
CPT® Codes DESCRIPTION
11920 Tattoing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less
11921 Tattoing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm
+11922 Tattoing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (list separately in addition to code for primary procedure) (use 11922 in conjunction with 11921)
11970 Replacement of tissue expander with permanent prosthesis 11971 Removal of tissue expander(s) without insertion of prosthesis 13100 Repair, complex, trunk; 1.1 cm to 2.5 cm
13101 Repair, complex, trunk; 2.6 cm to 7.5 cm
+13102 Repair, complex, trunk; each additional 5 cm or less (list separately in addition to code for primary procedure) (Use 13102 in conjunction with 13101)
19316 Mastopexy
19318 Reduction mammaplasty
19324 Mammaplasty, augmentation; without prosthetic implant
19325 Mammaplasty, augmentation; with prosthetic implant (for flap or graft, use also appropriate number)
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 Open periprosthetic capsulotomy, breast 19371 Periprosthetic capsulectomy, breast 19380 Revision of reconstructed breast
19396 Preparation of moulage for custom breast implant
*Current Procedural Terminology (CPT®) 2013 American Medical Association: Chicago, IL.
ICD-9 CM® Diagnosis Codes (List may not be all inclusive)
ICD-9 Codes DESCRIPTION
173.50 Unspecified Malignant Neoplasm of Skin Of Trunk, Except Scrotum 173.51 Basal Cell Carcinoma of Skin of Trunk, Except Scrotum
173.52 Squamous Cell Carcinoma of Skin of Trunk, Except Scrotum 174.0 Malignant neoplasm of nipple and areola of female breast 174.1 Malignant neoplasm of central portion of female breast 174.2 Malignant neoplasm of upper inner quadrant of female breast 174.3 Malignant neoplasm of lower inner quadrant of female breast 174.4 Malignant neoplasm of upper outer quadrant of female breast 174.5 Malignant neoplasm of lower outer quadrant of female breast 174.6 Malignant neoplasm of axillary tail of female breast
174.8 Malignant neoplasm of other specified sites of female breast 174.9 Malignant neoplasm of breast (female), unspecified site 175.0 Malignant neoplasm of nipple and areola of male breast
175.9 Malignant Neoplasm of Other and Unspecified Sites of Male Breast 198.81 Secondary malignant neoplasm of breast (Excludes skin of breast, 198.2)
217 Benign Neoplasm Of Breast
232.5 Carcinoma In Situ Of Skin Of Trunk Except Scrotum 233.0 Carcinoma in situ of breast
610.0 Solitary Cyst Of Breast 610.1 Diffuse Cystic Mastopathy 610.2 Fibroadenosis Of Breast 610.3 Fibrosclerosis Of Breast 610.4 Mammary Duct Ectasia
610.8 Other Specified Benign Mammary Dysplasias 610.9 Benign Mammary Dysplasia Unspecified
996.54 Mechanical complication due to breast prosthesis
996.69 Infection and inflammatory reaction due to other internal prosthetic device, implant or graft (i.e. Breast Prosthesis)
996.79 Other complications due to other internal (biological and/or synthetic) prosthetic
device, implant and graft
V10.3 Personal history of malignant neoplasm; breast
V45.71 Acquired absence of breast and nipple (Excludes congenital absence of breast and nipple, 757.6).
V50.41 Prophylactic organ removal; breast
V51.0 Encounter for breast reconstruction following mastectomy V52.4 Fitting and adjustment of breast prosthesis device and implant
*2013 ICD-9-CM®For Physicians, VOLUMES I & II, Professional Edition (American Medical Association).
HCPCS CODES (List may not be all inclusive)
HCPCS Codes Description
C1789 Prosthesis, breast (implantable) L8020 Breast prosthesis, mastectomy form
L8030 Breast prosthesis, silicone or equal, without integral adhesive L8031 Breast prosthesis, silicone or equal, with integral adhesive L8032 Nipple prosthesis, reusable, any type, each
L8035 Custom breast prosthesis, post mastectomy, molded to patient model L8039 Breast prosthesis, not otherwise specified
L8600 Implantable breast prosthesis, silicone or equal
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
S2068 Breast reconstruction with deep inferior epigastric perforator (DIEP) flap, or
superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral
*2013 HCPCS LEVEL II Professional Edition® (American Medical Association).
REFERENCES
1. 1998 Federal Breast Reconstruction Law (full document). Generated by the American Society of Plastic Surgeons (ASPS). Signed into Law on October 21 1998. Accessed March 19, 2013.
Available at URL address: http://www.plasticsurgery.org/reconstructive-procedures/breast- reconstruction/breast-reconstruction-resources/1998-federal-breast-reconstruction-law.html 2. Centers for Medicare and Medicaid Services. Local Coverage Determination (LCD): Cosmetic and
Reconstructive Surgery (L30733). Contractor Name: Wisconsin Physicians Service Insurance Corporation. Contractor Number: 00951. Original Determination Effective Date: For services performed on or after 11/15/2010. Revision Effective Date: For services performed on or after 01/01/2013. Accessed March 19, 2013. Available at URL address:
http://www.cms.gov/medicare-coverage-database/details/lcd-
details.aspx?LCDId=30733&ContrId=47&ver=19&ContrVer=1&CntrctrSelected=47*1&Cntrctr=47
&name=Wisconsin+Physicians+Service+Insurance+Corporation+(00951%2c+Carrier)&s=57&Doc Type=Active&bc=AggAAAIAAAAAAA%3d%3d&
3. Centers for Medicare and Medicaid Services. National Coverage Determination (NCD) for Breast Reconstruction Following Mastectomy. Publication Number: 100-3. Manual Section Number:
140.2. Effective date: 1/1/1997. Accessed March 19, 2013. Available at URL address:
http://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?NCDId=64&ncdver=1&bc=AgAAgAAAAAAAAA%3d%3d&
4. Centers for Medicare and Medicaid Services. Retired Local Coverage Determination (LCD) for Cosmetic and Reconstructive Surgery. Contractor name: Wisconsin Physicians Service Insurance Corporation. LCD ID Number: L17993. Effective date: 9/16/2004. Revision effective date:
12/1/2009. Original Determination Ending Date: 11/14/2010. Accessed March 19, 2013.
Available at URL address:
http://coverage.cms.fu.com/mcd_archive/viewlcd.asp?lcd_id=17993&lcd_version=20&show=all 5. ECRI Institute. DIEP Flap and TRAM Flap for Breast Reconstruction. Published: 2/20/2009.
Searched March 19, 2013. No longer available at URL address: www.ecri.org .
6. “Puerto Rico: Ley 186 Cirugía Reconstructiva (P. de la C. 186); Texto de Aprobación final por la Cámara, 19 de enero de 2010”. Accessed March 19, 2013. Available at URL address:
http://senado.pr.gov/Proyectos%20del%20Senado/pc0186-ta.pdf
7. “Senado de Puerto Rico. Informe Positivo sobre el P. del C. 186 sin enmiendas (23 de junio de 2011)”. Accessed March 19, 2013. Available at URL address: www.oslpr.org or at URL address:
https://docs.google.com/viewer?a=v&q=cache:suD--
xDG67IJ:www.oslpr.org/files/docs/%257BD53B1111-E43A-4061-B7A1-
9FDC19550C46%257D.doc+Ley+186+Cirug%C3%ADa+Reconstructiva+Puerto+Rico&hl=es- 419&gl=pr&pid=bl&srcid=ADGEESjVJGdWQ6F3ohlqyLqgcQDtLXvKthXEsk0zRBBJ_gtl1L7WG- iwDtOesZPpzIhSGXxPkWM9JvSOtB9Oq1FOZS0VtG_hCM450lmSbS8NiC_06eiNhMhU4TZjU- i64K0iQrq4iOA6&sig=AHIEtbRaIWsltqfrx87HiIGlP8Vcttq9aA
8. Women’s health and Cancer Rights Act (WHCRA). Federal Breast Reconstruction Law of 1998.
Accessed March 19, 2013. Available at URL address:
http://cciio.cms.gov/programs/protections/WHCRA/whcra_factsheet.html , or at URL address:
http://www.cancer.org/treatment/findingandpayingfortreatment/managinginsuranceissues/wo mens-health-and-cancer-rights-act
POLICY HISTORY
DATE ACTION COMMENT
March 11, 2010 Origination of Policy
March 24, 2011 Yearly Review 1. HCPCS Codes added to the policy L8020-L8039 2. CPT Codes added to the policy 19396
March 9, 2012 Yearly Review
March 19, 2013 Revised References updated. Added new References, numbers 1, 2, & 7.
To the Indications Section: Revised previous indication: Breast implant removal and subsequent reimplantation; and substituted with: Removal or revision of a breast implant is considered medically necessary when it is removed for one of the following reasons: Mechanical complication of breast prosthesis; including rupture or failed implant, implant extrusion;
Infection or inflammatory reaction due to a breast prosthesis; including infected breast implant, or rejection of breast implants; Other complication of internal breast implant; including siliconoma, granuloma, interference with diagnosis of breast cancer, painful capsular contracture with disfigurement.
To the Coding Information: added the new CPT Code 19355, and the new ICD-9 Codes 173.50 – 173.52, 175.9, 217, 232.5, 610.0 – 610.9, 996.54, 996.69, 996.79 & V51.8.
This document is for informational purposes only. It is not an authorization, certification, explanation of benefits, or contract. Receipt of benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with the terms of the member’s plan in effect as of the date services are rendered. Medical Card System, Inc., (MCS) medical policies are developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, Medical Card System, Inc., (MCS) reserves the right to review and update its medical policies at its discretion Medical Card System, Inc., (MCS) medical policies are intended to serve as a resource to the plan. They are not intended to limit the plan’s ability to interpret plan language as deemed appropriate. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment they choose to provide.
i Capsulotomy is a procedure in which part of the "capsule" of scar tissue surrounding a breast implant is removed or the tissue altered or released in some way.
ii Capsulectomy is a procedure in which the entire "capsule" of scar tissue surrounding a breast implant is surgically removed.
iii Mastopexy or breast lift surgery refers to a group of elective surgical operations designed to lift or change the shape of a person's breasts.
