Mastectomy

Mastectomy may be considered medically necessary for the symptoms and diagnosis, or treatment of the member's condition, illness, or injury.

The type of mastectomy (subcutaneous, partial, modified, or radical) and the timing of the surgery vary for each patient and are determined by the surgeon.

Mastectomy for Fibrocystic Breasts

Fibrocystic breasts are considered a condition or a disorder with or without mild to severe symptoms.

Mastectomy for fibrocystic breasts may be considered medically necessary:

• When the patient is symptomatic;* and
• Has been unresponsive to conservative treatment**; and/or
• A biopsy has been performed.

*Symptoms of fibrocystic breasts include, but are not limited to: breast engorgement attended by pain and tenderness, generalized lumpiness or isolated mass or cyst.

**Conservative treatment for fibrocystic breasts consists of, but is not limited to: support bras, avoiding trauma, avoiding caffeine, medication for pain, anti-inflammatory drugs, hormonal manipulation, use of vitamin E, use of diuretics, and salt restrictions.

Nipple Sparing Mastectomy (NSM)

Nipple sparing/skin sparing mastectomy may be considered medically necessary when there is no cancer involving the skin, nipple or areola.

Removal of Breast Implant

Removal of a silicone gel-filled breast implant may be considered medically necessary:

• In all cases for a documented implant rupture, infection, extrusion, Baker class IV contracture, in cases of surgical treatment of breast cancer.

Removal of a saline-filled breast implant may be considered medically necessary for EITHER of the following indications:

• In  a documented implant rupture for those patients who had originally undergone breast implantation for reconstructive purposes; or
• In cases of infection, extrusion, Baker class IV contracture, or surgical treatment of breast cancer.

Removal of a breast implant associated with a Baker class III contracture may be considered medically necessary:

• In those patients who had originally undergone breast implantation for reconstructive purposes.

The following indications for removal of breast implants are considered not medically necessary:

• Systemic symptoms, attributed to connective tissue diseases, autoimmune diseases, etc.; or
• Patient anxiety; or
• Baker class III contractures in patients with implants for cosmetic purposes; or
• Rupture of a saline implant in patients with implants for cosmetic purposes; or
• Pain not related to contractures or rupture.

Reconstructive Surgery

Reconstructive breast surgery may be considered medically necessary for ANY of the following indications:

• After a medically necessary mastectomy; or
• Accidental injury; or
• Trauma.

Reconstructive breast surgery after removal of an implant may be considered medically necessary:

• Only in those patients who had originally undergone breast implantation for reconstructive purposes.

Reconstruction may be performed by an implant-based approach or through the use of autologous tissue.

Removal of implants requires documentation of the original indication for implantation and the type of implant, either saline- or silicone gel-filled, and the current symptoms, either local or systemic.

Refer to Table Attachment for a chart to assist with medical necessity determination for implant removal.

Surgery on the Contralateral Breast to Produce Symmetry

Surgery* on the contralateral breast to produce a symmetrical appearance after removal of an implant and re-implantation may be considered reconstructive and medically necessary:

• When the implant was originally placed for reconstructive purposes in an individual with a history of mastectomy, lumpectomy or treatment of breast cancer.

* Types of reconstructive surgical procedures on the diseased breast include, but are not limited to:

• Nipple/areola reconstruction.
• Nipple tattooing will be covered if the medical necessity criteria for reconstructive breast surgery is met.
  • Nipple tattooing is considered cosmetic for all other indications.
• Transverse rectus abdominis myocutaneous flap (TRAM), latissimus dorsi flap or free flap.
• Preparation of moulage for custom breast implant.
• Augmentation mammoplasty.
• Reduction mammoplasty.
• Mastopexy.

Services that do not meet the criteria of this policy will be considered not medically necessary.

Breast Prosthetics

The following breast prosthetics are medically necessary:

• Breast prosthesis, mastectomy bra.
• Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral.
• Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral.
• Breast prosthesis, mastectomy sleeve.
• Breast prosthesis, mastectomy form. 
• Breast prosthesis, silicone or equal.
• Breast prosthesis, not otherwise specified.
• Adhesive skin support attachment for use with external breast prosthesis, each.
• External breast prosthesis garment, with mastectomy form, post mastectomy.
• Custom breast prosthesis, post mastectomy, molded to patient model.
• Implantable breast prosthesis, silicone or equal.
• Camisole, post-mastectomy.
• Breast prosthesis, silicone or equal, with integral adhesive.
• Nipple prosthesis, reusable, any type, each.

NOTE:

When the implantable breast prosthesis is provided by the hospital, the charge should be billed as a hospital expense.

When the physician incurs the cost of the breast implant, the charge should be billed as a professional expense.

Charges for implantable breast prosthesis should be denied as cosmetic when the implant is provided in conjunction with a cosmetic augmentation mammoplasty.

Please see Table Attachment for quantity limits.

The Women's Health and Cancer Rights Act of 1998 (WHCRA) is federal legislation that provides that any individual, with insurance coverage who is receiving benefits in connection with a mastectomy covered by their benefit plan (whether or not for cancer) who elects breast reconstruction, must receive coverage for the reconstructive services as provided by WHCRA. This mandate further defines coverage for the following:

• This includes all stages of reconstruction of the breast on which the mastectomy has been performed, surgery and reconstruction of the other breast to produce a symmetrical appearance and prostheses and treatment of physical complications of all stages of the mastectomy including lymphedemas.
• If additional surgery is required for either breast for treatment of physical complications of the implant or reconstruction, surgery on the other breast to produce a symmetrical appearance is reconstructive at that point as well. 
• Prostheses and physical complications all stages of mastectomy, including lymphedemas; in a manner determined in consultation with the attending physician and the patient.
• Cancer does not have to be the reason for the mastectomy.
• The mandate applies to men, as well as women.

Delaware Mandate: Delaware law, 18 Del. C. Sections 3347 and 3563 adopted the requirements of federal law under the Woman’s Health and Cancer Rights Act of 1998 (29 USC 1185 Section 713 (1998))  which requires both individual and group coverage for breast reconstruction post covered mastectomy. Coverage is required for:

• All stages of reconstruction of the breast on which the mastectomy has been performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• Prostheses and physical complications of mastectomy, including lymphedemas.
  
• Reconstructive breast surgery is defined as those surgical procedures designed to restore the normal appearance of a breast following a mastectomy.  Reconstructive surgery includes all surgery on the affected breast and surgery on the contralateral normal breast to re-establish symmetry between the two breasts or to alleviate functional impairment caused by the mastectomy.
• Symmetry is defined as approximate equality in size and shape of the non-diseased breast with the diseased breast after definitive reconstructive surgery on the diseased or non-diseased breast has been performed.