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Augmentation mammoplasty is performed to reconstruct congenital or acquired deformities, or to enhance appearance. It may be reconstructive or cosmetic in nature. Augmentation mammoplasty is accomplished by inserting a mammary implant prosthesis beneath the chest tissues to increase size and modify abnormal breast shape. Implants may be placed either directly beneath the breast gland or beneath the underlying muscle.

Generally, the overlying chest skin envelope has sufficient elasticity to adapt to the increased size, but occasionally tissue expansion must be performed over several months to provide adequate skin for reconstruction. In some instances where there are associated chest wall deformities, customized implants based on a moulage may be fabricated to achieve adequate reconstruction.

Augmentation mammoplasty may be associated in immediate reconstruction or delayed reconstruction following mastectomy or mastopexy.

When augmentation mammoplasty is performed for cosmetic purposes benefits are specifically excluded.

When breast augmentation surgery is performed, clinical signs and symptoms should be documented by the surgeon in the history and physical and reiterated in the operative note. Justification for surgery should be based on the outcome probability of repairing disfigurement, or meeting other reconstructive goals.

Outlined below is a listing of examples for which augmentation mammoplasty may be considered reconstructive. This listing is not inclusive of all situations for which augmentation mammoplasty may be eligible for reimbursement:

• Agenesis or severe hypoplasia with breast asymmetry resulting in a deformity of 50% or greater in contralateral breast,
• Scoliosis,
• Poland's Syndrome, or
• Chest wall deformity such as pectus excavatum, and as such may be bilateral or unilateral.
• Augmentation may be indicated to reconstruct breasts damaged by infection, traumatic loss, scarring, burns or X-ray therapy.
• Breast reconstruction by augmentation following prophylactic mastectomy, subcutaneous mastectomy, and segmental or radical mastectomy for cancer is accepted and may be done simultaneously or at a later time.
• Breast asymmetry requiring augmentation for correction after resection of a benign breast lesion which results in a 50% deformity or greater in the contralateral breast.

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.

None

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

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

3/6/2002: Individual consideration requirement deleted

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

9/4/2002: CPT code 11970 re-added

7/30/2004: Code Reference section updated, ICD-9 procedure codes 85.50, 85.51, 85.52, 85.53, 85.54, 85.95, 85.96 added, ICD-9 diagnosis code V10.3 added

7/29/2005: Code Reference section updated, ICD-9 diagnosis code 996.54, 996.69, 996.79 added with note: "Breast prosthesis complications covered if prosthesis was covered," HCPCS L8600 added

03/08/2006: Coding updated. CPT4 2006 revisions added to policy

9/19/2008: 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. New ICD-9 diagnosis code 209.35 added to covered table.

ASPRS Paper

Medical Policy Advisory Committee (02/1993)

Covered Codes

*Some covered procedure codes have multiple descriptions. Coverage will only be made for covered codes when used for services outlined within the policy statement section. 

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