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Reports of use of this tissue matrix (allograft) in breast reconstructive surgery are being published. Most reports describe use of the allograft to create a “hammock” or “sling” to provide improved inferior and lateral support for breast implants. This has been used in immediate and delayed reconstruction as well as in revision of prior reconstructive surgery. There also is some interest in using the allograft in nipple reconstruction post-mastectomy.

The potential advantages of using this device are to reduce the total time for reconstructive surgery post-mastectomy, minimize the likelihood of implant migration, and improve esthetic outcomes. For example, use of the allograft may allow for implantation of a silicone implant during immediate reconstruction in some patients.

AlloDerm is an acellular dermal matrix (allograft) derived from donated human skin tissue supplied by US AATB-compliant tissue banks utilizing the standards of the American Association of Tissue Banks (AATB) and U.S. Food and Drug Administration's (FDA) guidelines. Since AlloDerm is regarded as minimally processed and not significantly changed in structure from the natural material, the FDA has classified it as banked human tissue.

Note:  This policy only addresses use of the allograft material for use in breast reconstructive surgery.  

• When there is insufficient tissue expander or implant coverage by the pectoralis major muscle and additional coverage is required,
• When there is viable but compromised or thin post-mastectomy skin flaps that are at risk of dehiscence or necrosis, or
• The infra-mammary fold and lateral mammary folds have been undermined during mastectomy and re-establishment of these landmarks is needed

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

3/27/2008: Reviewed and approved by the Medical Policy Advisory Committee (MPAC)

12/24/2008: Code reference section updated per the 2009 CPT/HCPCS revisions

05/15/2009: Policy updated to include medically necessary indications. Code reference setion updated.  HCPC code Q4100, ICD-9 codes 174.0-174.9, 233.0, V10.3, V45.71 added to policy

12/01/2011: Policy reviewed. Policy statement unchanged.  Removed deleted HCPCS code J7344 from the Code Reference section.

05/09/2012: Policy reviewed; no changes.

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

Covered Codes

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