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DESCRIPTIONTo 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.
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).
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.
POLICYIn 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:
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.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
POLICY HISTORY2/1993: 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.
08/28/2015: Code Reference section updated for ICD-10. Removed ICD-9 procedure codes 85.36 and 85.41 - 85.48. Removed deleted CPT code 14300.
06/01/2016: Policy number added. Policy Guidelines updated to add medically necessary definition.
09/30/2016: Code Reference section updated to add new ICD-10 diagnosis codes N61.0 and N61.1. Added CPT Code 15777, effective 10/01/2016.
Blue Cross Blue Shield Association policy # 7.01.22
CODE REFERENCEThis 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.