HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
S-129-028
Topic:
Mastectomy and Reconstructive Surgery
Section:
Surgery
Effective Date:
November 23, 2020
Issued Date:
November 23, 2020
Last Revision Date:
October 2020
Annual Review:
October 2020
 
 

Mastectomy is the removal of all or part of a breast and is typically performed as a treatment for cancer, or in some cases for the treatment of benign disease.

Reconstructive breast surgery is defined as surgical procedures performed that restore the normal appearance of a breast. Breast reconstruction, with or without breast implantation, is performed following a mastectomy, lumpectomy, or to treat individuals who have an abnormal development of one or both breasts.

Lumpectomy is the removal of the breast tumor and surrounding tissue.

Policy Position

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.

Pennsylvania Act 51-1997, effective 02/01/1998 and Pennsylvania Act 44 of 2020 requires coverage for reconstructive surgery and prosthetic devices incident to a mastectomy. This mandate further defines the following:

  • 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.
  • Prosthetic Devices are defined as the use of initial and subsequent artificial devices including custom artificial devices, to replace the removed breast or portions of the breast.
  • Home health- This mandate requires coverage for a home health visit when a woman is discharged within 48 hours following her admission for a mastectomy.
  • Coverage for the services defined in this mandate are subject to any copayments, coinsurances or deductibles, and all other terms and conditions, set forth in the patient's contract

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.

19301

19302         

19303         

19305         

19306         

19307

 


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 individual 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.

19301

19302         

19303         

19305         

19306         

19307

 


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.

19303

 

 

 

 

 

 


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 individuals 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 individuals 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
  • Individual's anxiety; or
  • Baker class III contractures in individuals with implants for cosmetic purposes; or
  • Rupture of a saline implant in individuals with implants for cosmetic purposes; or
  • Pain not related to contractures or rupture.

19328

19330

 

 

 

 

 


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 individuals 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.

11920

11921

11922

19316

19318

19324

19325

19328

19330

19340

19342

19350

19357

19361

19364

19367

19368

19369

19396

19499

S2066

S2067

S2068

 

 

 

 

 


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 are 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.

11920

11921

11922

19316

19318

19324

19325

19328

19330

19340

19342

19350

19357

19361

19364

19367

19368

19369

19396

19499

S2066

S2067

S2068

 

 

 

 

 


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.
  • Custom artificial devices.
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.

19324

19325

L8000

L8001

L8002

L8010

L8015

L8020

L8030

L8031

L8032

L8033

L8035

L8039

L8600

A4280

S8460

 

 

 

 


C1789

 

 

 

 

 

 


Related Policies

Refer to Medical Policy, S-163, Prophylactic Mastectomy, for additional information.

Refer to Medical Policy S-28, Cosmetic Surgery vs. Reconstructive Surgery, for additional information.


Place of Service: Inpatient/Outpatient

Mastectomy and reconstructive surgery is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.


Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: 
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as: 
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator. 

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services 
200 Independence Avenue, SW 
Room 509F, HHH Building 
Washington, D.C. 20201 
1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.