Print Breast Reconstruction Following Mastectomy

Breast Reconstruction Following Mastectomy

 

DESCRIPTION

To replace a breast that has been surgically removed, a breast mound must first be reconstructed using alloplastic (non-self) materials, such as implants; or autogenous (self) tissues, such as flaps and grafts. A new nipple/areola can be reconstructed when the breast mound has "settled" and its final position has been established. Breast reconstruction may be performed immediately (at the time of mastectomy), or delayed (several months or even years following mastectomy). The timing should be determined by the surgeon, in consultation with the patient and other involved physicians.

A variety of techniques for breast reconstruction are available to accommodate the wide range of deformities resulting from mastectomy. Choice of the appropriate surgical technique must be made by the surgeon and will depend on the individual circumstances and needs of the patient.

Currently accepted techniques for reconstruction of a breast include:

Insertion of a Breast Implant

In some patients with adequate soft tissues, insertion of an alloplastic breast prosthesis underneath the skin or muscle of the chest will create a satisfactory breast mound.

Tissue Expansion

In some patients the skin covering their chest does not have enough elasticity to accommodate insertion of a breast prosthesis. To increase the amount of soft tissue available, a silicone tissue expander is placed beneath the skin or chest muscle. Over a period of time, saline is injected into the expander, causing the tissue to stretch. A second surgical procedure is usually required to remove the tissue expander and replace it with a permanent breast prosthesis.

Regional Tissue Transfer

When muscle and skin are insufficient or missing, it may be necessary to use an adjacent skin flap from the chest, abdomen, or back. The transverse rectus abdominis musculocutaneous (TRAM) flap is frequently used. It has the advantage of providing relatively large amounts of tissue for reconstruction, usually avoiding implant use, and leaving an acceptable donor site defect. Microsurgical techniques may be useful to augment TRAM-flap circulation when necessary to ensure flap viability. The latisimus dorsi flap is another regional flap that is used frequently. This flap, while it provides additional tissue, often requires an implant as well to provide adequate contour.

Distant Tissue Transfer (Free-Flap)

Sometimes, when adequate local or regional tissues are unavailable for reconstruction, it is necessary to use a free-flap transfer. This technique involves transplanting distant skin and underlying tissue along with the veins and arteries and reconnecting this flap to a "new" local blood supply under microscopic magnification. Microsurgical free-tissue transfer, using one of several donor sites, may be used to avoid implants in certain individuals. However, placement of a breast implant may be necessary as an adjunct to any flap procedure when insufficient tissue is obtained.

Reconstruction of the Nipple/Areolar Complex

Secondary surgery to provide optimal results involves restoration of a simulated nipple and surrounding areolar complex on the reconstructed breast mound. Available techniques include skin grafts, flaps, tattooing, and --occasionally-- transplantation of tissues from the opposite breast.

Surgery on the Opposite Breast

Because of the limitations of the current available techniques, reconstruction of a new breast mound often results in a shape and contour that is significantly different from the remaining, opposite (contralateral) breast. Because the breasts are paired organs, reconstructive surgery on the contralateral breast is therefore often necessary to achieve the best possible match of size and configuration. These surgical procedures may include reduction mammoplasty (reduction of the size of the breast), mastopexy (correction of the drooping breast) or implant mammoplasty (augmentation).

Miscellaneous Procedures

Frequently, additional surgical procedures may be required to achieve an optimal final reconstructive result. These may include excision of redundant tissue, repositioning of an implant, release of internal scar tissue, creation of an inframammary fold, scar revision, and other tissue rearrangement.

 

POLICY

In accordance with the Women's Health and Cancer rights Act of 1998 (WHCRA), all group health insurance as well as individual contracts that provide coverage for a mastectomy must comply with the following requirements:
If the Member elects reconstructive breast surgery connected with any medically necessary mastectomy, benefits will be provided for the following covered services:
  • Reconstruction of the breast on which the mastectomy was performed;
  • Surgery on the unaffected breast that is required to "produce a symmetrical appearance", and
  • Prostheses and treatment of complications of any state of a mastectomy, including lymphedema

Documentation should be provided which supports that the mastectomy was performed due to a disease process, congenital absence of one breast (Poland's Syndrome) or to restore bodily function or correct deformity resulting from disease, trauma or complication of previous surgery.

Breast reconstruction following mastectomy is performed to create a simulated breast and restore a sense of "wholeness" to the individual. Since breasts are paired organs, the ultimate result is to achieve bilateral symmetry. This may require surgery on the contralateral breast in cases of unilateral mastectomy. Restoration of both breasts following mastectomy is considered reconstructive and should be eligible for coverage.

 

POLICY EXCEPTIONS

None

 

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

 

POLICY HISTORY

2/1993: Approved by Medical Policy Advisory Committee (MPAC)

10/1998: Women's Health and Cancer Rights Act of 1998 (WHCRA)

4/5/2001: Policy reviewed; Managed Care Requirements deleted

7/16/2001: CPT codes 11960 and 11970 deleted; 19357 added

4/18/2002: Type of Service and Place of Service deleted

5/14/2002: Code Reference section updated; CPT codes 19180, 19182, 19328 and 19330 deleted

9/4/2002: Code Reference section updated; CPT code 11970 re-added

11/1/2002: ICD-9 diagnosis code V50.41 deleted

12/19/2003: Code Reference section updated, CPT code 15755, 19362 deleted, ICD-9 diagnosis code range 174.0-174.9, 175.0-175.9 listed separately

03/10/2006: Coding updated. HCPCS 2006 revisions added to policy

12/27/2006: Code Reference section updated per the 2007 CPT revisions

6/14/2007: Code Reference section updated per quarterly HCPCS and Category III revisions

9/22/2008: Annual ICD-9 updates effective 10-1-2008 applied

9/30/2009: Code reference section updated. Code description revised for ICD-9 diagnosis code 757.6. ICD-9 code 85.7 deleted from covered table due to code deleted as of 9-30-2008

12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions.

05/06/2013: Policy reviewed; no changes.

 

SOURCES

ASPRS Paper

Master Contract

Blue Cross Blue Shield Association policy # 7.01.22

 

CODE REFERENCE

This is may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Covered Codes

Code Number

Description

CPT-4

00402

Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum, reconstructive procedures on the breast (eg, reduction or augmentation mammoplasty, muscle flaps)

11920

Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less

11970 

Replacement of tissue expander with permanent prosthesis

11971

Removal of tissue expander(s) without insertion of prosthesis

14000

Adjacent tissue transfer or rearrangement, truck; defect 10 sq cm or less

14001

Adjacent tissue transfer or rearrangement, trunk, defect 10.1 sq cm to 30.0 sq cm

14300

Adjacent tissue transfer or rearrangement, more than 30 sq cm, unusual or complicated, any area (Deleted 12-31-2009)

14301

Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm (New 1-1-2010)

14302

Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to primary procedure) (New 1-1-2010)

15734

Muscle, myocutaneous, or fasciocutaneous flap; trunk

15740

Flap; island pedicle

19316

Mastopexy

19318

Reduction mammoplasty

19324 

Mammaplasty, augmentation; without prosthetic implant

19325

Mammoplasty, augmentation, with prosthetic implant

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

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 techniques

19367

Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle; with microvascular anastomosis

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

19370

Open periprosthetic capsulotomy, breast

19371

Periprosthetic capsulectomy, breast

19380

Revision of reconstructed breast

19396

Preparation of moulage for custom breast

ICD-9 Procedure

85.35

Bilateral subcutaneous mammectomy with synchronous implant

85.36 

Other bilateral subcutaneous mammectomy 

85.41 

Unilateral simple mastectomy

85.42 

Bilateral simple mastectomy

85.43 

Unilateral extended simple mastectomy

85.44 

Bilateral extended simple mastectomy

85.45 

Unilateral radical mastectomy

85.46 

Bilateral radical mastectomy

85.47 

Unilateral extended radical mastectomy

85.48 

Bilateral extended radical mastectomy

85.50 

Augmentation mammoplasty, not otherwise specified

85.51 

Unilateral injection into breast for augmentation

85.52 

Bilateral injection into breast for augmentation

85.53 

Unilateral breast implant

85.54 

Bilateral breast implant

85.6 

Mastopexy 

85.70, 85.71, 85.72, 85.73, 85.74, 85.75, 85.76, 85.79

Total reconstruction of breast code range

85.82 

Split-thickness graft to breast

85.83 

Full-thickness graft to breast

85.84 

Pedicle graft to breast

85.85 

Muscle flap graft to breast

85.86 

Transposition of nipple

85.87 

Other repair or reconstruction of nipple

85.89 

Other mammoplasty 

85.93 

Revision of implant of breast

85.94 

Removal of implant of breast

85.95 

Insertion of breast tissue expander

85.96 

Removal of breast tissue expander (s)

86.02 

Injection or tattooing of skin lesion or defect

86.70 

Pedicle or flap graft, not otherwise specified

86.71 

Cutting and preparation of pedicle grafts or flaps

86.72 

Advancement of pedicle graft

86.74 

Attachment of pedicle or flap graft to other sites

ICD-9 Diagnosis

172.5

Malignant melanoma 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 

198.2

Secondary malignant neoplasm of skin

198.81

Secondary malignant neoplasm of breast

232.5

Carcinoma in situ of skin of trunk, except scrotum

233.0

Carcinoma in situ of breast

610.2

Fibroadenosis of breast

610.3

Fibrosclerosis of breast

611.0

Inflammatory disease of breast

757.6

Specified congenital anomalies of breast

942.01 

Burn of trunk, unspecified degree of breast

942.11 

Erythema due to burn (first degree) of breast

942.21 

Blisters with epidermal loss due to burn (second degree) of breast

942.31 

Full-thickness skin loss due to burn (third degree nos) of breast

942.41 

Deep necrosis of underlying tissues due to burn (deep third degree) of breast, without mention of loss of a body part

942.51 

Deep necrosis of underlying tissues due to burn (deep third degree) of breast, with loss of a body part

959.19

Other injury of other sites of trunk

V51.0

Encounter for breast reconstruction following masectomy 

HCPCS

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 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

 

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