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L.7.01.403
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.
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.
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.
11/5/2003: Code Reference section updated, codes deleted from "Description" and "Policy" sections, ICD-9 diagnosis codes 611.8, 611.9, 906.9 deleted.
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.
10/30/2013: Policy reviewed; no changes.
08/21/2015: Code Reference section updated to add ICD-10 codes and to add ICD-9 procedure codes 85.55, 85.70, 85.71, 85.73, 85.74, 85.75, 85.76, 85.79, 85.82, 85.83, and 85.89. ICD-9 diagnosis code 173.5 extended to the fifth digit (173.50 - 173.59).
09/11/2015: Removed ICD-9 procedure code 85.55 from the Code Reference section. This code is specifically addressed in the Autologous Fat Grafting to the Breast and Adipose-derived Stem Cells medical policy.
06/01/2016: Policy number L.7.01.403 added.
09/30/2016: Code Reference section updated to add new ICD-10 diagnosis codes N61.0 and N61.1.
10/05/2017: Code Reference section updated to remove deleted ICD-10 diagnosis codes N61, T85.81XA - T85.89, and ICD-9 diagnosis code 996.79.
09/30/2019: Code Reference section updated regarding deleted ICD-10 procedure codes.
09/30/2020: Code Reference section updated to add new ICD-10 diagnosis codes N61.20, N61.21, N61.22, and N61.23, effective 10/01/2020. Removed deleted ICD-10 procedure codes 0H0TX7Z, 0H0TXKZ, 0H0UX7Z, 0H0UXKZ, 0HRUX7Z, 0HRUXJZ, 0HRUXKZ, 0HUTX7Z, 0HUUX7Z, 0HUUXJZ, 0HUUXKZ, 0H0VX7Z, 0H0VXJZ, 0H0VXKZ, 0HRTX7Z, 0HRTXKZ, and 0HRTXJZ.
12/15/2020: Code Reference section updated to revise code descriptions for CPT codes 11970, 19325, 19340, 19342, and 19357, effective 01/01/2021.
10/12/2022: Policy reviewed. Policy statements unchanged. Code Reference section updated to remove deleted CPT code 19324.
08/21/2023: Policy reviewed; no changes.
08/28/2024: Policy reviewed; no changes.
10/01/2024: Code Reference section updated to add new ICD-10 procedure codes 0HRT07B, 0HRU07B, and 0HRV07B.
10/01/2025: Code Reference section updated to add new ICD-10 diagnosis codes C50.A0, C50.A1, and C50.A2.
ASPRS Paper
Medical Policy Advisory Committee (02/1993)
This 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.
Code Number | Description | ||
CPT-4 | |||
00402 | Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum, reconstructive procedures on breast (eg, reduction or augmentation mammoplasty, muscle flaps) | ||
11970 | Replacement of tissue expander with permanent implant | ||
19325 | Breast augmentation with implant | ||
19340 | Insertion of breast implant on same day of mastectomy (ie, immediate) | ||
19342 | Insertion or replacement of breast implant on separate day from mastectomy | ||
19357 | Tissue expander placement in breast reconstruction, including subsequent expansion(s) | ||
19396 | Preparation of moulage for custom breast implant | ||
HCPCS | |||
L8600 | Implantable breast prosthesis, silicone or equal | ||
ICD-9 Procedure | ICD-10 Procedure | ||
85.50, 85.51, 85.52, 85.53, 85.54 | Augmentation mammoplasty | 0H0T07Z, 0H0T0JZ, 0H0T0KZ, 0H0T3JZ, 0H0T3KZ, 0H0T0ZZ, 0H0T37Z, 0H0T3JZ, 0H0T3KZ, 0H0T3ZZ, 0H0TXJZ, 0H0TXZZ, 0H0U07Z, 0H0U0JZ, 0H0U0KZ, 0H0U0ZZ, 0H0U37Z, 0H0U3JZ, 0H0U3KZ, 0H0U3ZZ, 0H0UX7Z, 0H0UXJZ, 0H0UXZZ, 0H0V07Z | Alteration of breast (right, left, bilateral), by approach |
0HRT075, 0HRT076, 0HRT077, 0HRT078, 0HRT079, 0HRT07Z, 0HRT0JZ, 0HRT0KZ, 0HRT37Z, 0HRT3JZ, 0HRT3KZ, 0HRTX7Z, 0HRTXJZ, 0HRTXKZ, 0HRU075, 0HRU076, 0HRU077, 0HRU078, 0HRU079, 0HRU07Z, 0HRU0JZ, 0HRU0KZ, 0HRU37Z, 0HRU3JZ, 0HRU3KZ | Replacement of breast (right, left or bilateral), by approach | ||
0HUU07Z, 0HUU0JZ, 0HUU0KZ, 0HUU37Z, 0HUU3JZ, 0HUU3KZ, 0HUU77Z, 0HUU7JZ, 0HUU7KZ, 0HUU87Z, 0HUU8JZ, 0HUU8KZ, 0HUT07Z, 0HUT0JZ, 0HUT0KZ, 0HUT37Z, 0HUT3JZ, 0HUT3KZ, 0HUT77Z, 0HUT7JZ, 0HUT7KZ, 0HUT87Z, 0HUT8JZ, 0HUT8KZ | Supplement of breast (right, left, bilateral), by approach | ||
0H0UXKZ, 0H0V07Z, 0H0V0JZ, 0H0V0KZ, 0H0V37Z, 0H0V3JZ, 0H0V3KZ | Alteration of left breast with nonautologous tissue substitute, by approach | ||
0HUV0JZ, 0HUV3JZ | Supplement bilateral breast with synthetic substitute, by approach | ||
85.70 85.79 | Total reconstruction of breast, not otherwise specified Other total reconstruction of breast | 0HRT07Z | Replacement of right breast with autologous tissue substitute, open approach |
0HRU07Z | Replacement of left breast with autologous tissue substitute, open approach | ||
85.71 | Latissimus dorsi myocutaneous flap | 0HRT075 | Replacement of right breast using latissimus dorsi myocutaneous flap, open approach |
0HRU075 | Replacement of left breast using latissimus dorsi myocutaneous flap, open approach | ||
85.73 | Transverse rectus abdominis myocutaneous (TRAM) flap, free | 0HRT076 | Replacement of right breast using transverse rectus abdominis myocutaneous flap, open approach |
0HRU076 | Replacement of left breast using transverse rectus abdominis myocutaneous flap, open approach | ||
85.74 | Deep inferior epigastric artery perforator (DIEP) flap, free | 0HRT077 | Replacement of right breast using deep inferior epigastric artery perforator flap, open approach |
0HRU077 | Replacement of left breast using deep inferior epigastric artery perforator flap, open approach | ||
85.75 | Superficial inferior epigastric artery (SIEA) flap, free | 0HRT078 | Replacement of right breast using superficial inferior epigastric artery flap, open approach |
0HRU078 | Replacement of left breast using superficial inferior epigastric artery flap, open approach | ||
85.76 | Gluteal artery perforator (GAP) flap, free | 0HRT079 | Replacement of right breast using gluteal artery perforator flap, open approach |
0HRU079 | Replacement of left breast using gluteal artery perforator flap, open approach | ||
0HRTXKZ | Replacement of right breast with nonautologous tissue substitute, external approach | ||
85.83 | Full-thickness graft to breast | 0HRTX7Z | Replacement of right breast with autologous tissue substitute, external approach |
85.89 | Other mammoplasty | 0H0T0ZZ | Alteration of right breast, open approach |
0H0U0ZZ | Alteration of left breast, open approach | ||
0HRT07B, 0HRU07B, 0HRV07B | Replacement of breast (right, left, or bilateral) using lumbar artery perforator flap, open approach | ||
0HRT07Z | Replacement of right breast with autologous tissue substitute, open approach | ||
0HRT37Z | Replacement of right breast with autologous tissue substitute, percutaneous approach | ||
0HRU07Z | Replacement of left breast with autologous tissue substitute, open approach | ||
85.95 | Insertion of breast tissue expander | 0HHT0NZ, 0HHU0NZ, 0HHV0NZ | Insertion of tissue expander into breast (right, left, bilateral), open approach |
85.96 | Removal of breast tissue expander (s) | 0HPT0NZ, 0HPU0NZ | Removal of tissue expander from breast (right or left), open approach |
ICD-9 Diagnosis | ICD-10 Diagnosis | ||
172.5 | Malignant melanoma of skin of trunk, except scrotum | C43.52 | Malignant melanoma of skin breast |
D03.52 | Melanoma in situ of breast (skin) (soft tissue) | ||
173.50-173.59 | Other malignant neoplasm of skin of trunk, except scrotum | C44.501 | Unspecified malignant neoplasm of skin of breast |
C44.511 | Basal cell carcinoma of skin of breast | ||
C44.521 | Squamous cell carcinoma of skin of breast | ||
C44.591 | Other specified malignant neoplasm of skin of breast | ||
174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.6, 174.8, 174.9 | Malignant neoplasm of female breast | C50.011 - C50.019,C50.111 - C50.119,C50.211 - C50.219,C50.311 - C50.319,C50.411 - C50.419,C50.511 - C50.519,C50.611 - C50.619,C50.811 - C50.819,C50.911 - C50.919 | Malignant neoplasm breast, female (code ranges) |
175.0, 175.9 | Malignant neoplasm of male breast | C50.021 - C50.029,C50.121 - C50.129,C50.221 - C50.229,C50.321 - C50.329,C50.421 - C50.429,C50.521 - C50.529,C50.621- C50.629,C50.821 - C50.829,C50.921 - C50.929 | Malignant neoplasm breast, male (code ranges) |
C50.A0, C50.A1, C50.A2 | Malignant inflammatory neoplasm of breast (New 10/01/2025) | ||
198.2 | Secondary malignant neoplasm of skin | C79.2 | Secondary malignant neoplasm of skin |
198.81 | Secondary malignant neoplasm of breast | C79.81 | Secondary malignant neoplasm breast |
209.35 | Merkel cell carcinoma of the trunk | C4A.52 | Merkel cell carcinoma of skin of breast |
232.5 | Carcinoma in situ of skin of trunk, except scrotum | D04.5 | Carcinoma in situ of skin of trunk |
233.0 | Carcinoma in situ of breast | D05.00 - D05.92 | Carcinoma in situ of breast (code range) |
610.2 | Fibroadenosis of breast | N60.21 - N60.29 | Fibroadenosis of breast (code range) |
610.3 | Fibrosclerosis of breast | N60.31 - N60.39 | Fibrosclerosis of breast (code range) |
611.0 | Inflammatory disease of breast | N61.0, N61.1 | Inflammatory disorders of breast |
N61.20, N61.21, N61.22, N61.23 | Granulomatous mastitis | ||
611.82 | Hypoplasia of breast | N64.82 | Hypoplasia of breast |
611.83 | Capsular contracture of breast implant | N64.89 | Other specified disorders of breast |
612.0 | Deformity of reconstructed breast | N65.0 | Deformity of reconstructed breast |
612.1 | Disproportion of reconstructed breast | N65.1 | Disproportion of reconstructed breast |
709.2 | Scar condition and fibrosis of skin | L90.5 | Scar condition and fibrosis of skin |
754.2 | Congenital musculoskeletal deformity of spine | Q67.5 | Congenital deformity of spine |
Q76.3 | Congenital scoliosis due to congenital bony malformation | ||
754.81, 754.82, 754.89 | Other specified nonteratogenic anomalies | Q67.6, Q67.7, Q67.8 | Congenital musculoskeletal deformities of head, face, spine and chest |
756.81 | Congenital absence of muscle and tendon | Q79.8 | Other congenital malformations of musculoskeletal system |
757.6 | Specified congenital anomalies of breast | Q83.0 - Q83.9 | Congenital malformations of breast (code range) |
909.2 | Late effect of radiation | L59.9 | Disorders of the skin and subcutaneous tissue related to radiation, unspecified |
942.01 | Burn of trunk, unspecified degree of breast | T21.01XA | Burn of unspecified degree of chest wall, initial encounter |
T21.41XA | Corrosion of unspecified degree of chest wall, initial encounter | ||
942.11 | Erythema due to burn (first degree) of breast) | T21.11XA | Burn of first degree of chest wall, initial encounter |
T21.51XA | Corrosion of first degree of chest wall, initial encounter | ||
942.21 | Blisters with epidermal loss due to burn (second degree) of breast | T21.21XA | Burn of second degree of chest wall, initial encounter |
T21.61XA | Corrosion of second degree of chest wall, initial encounter | ||
942.31942.41 | Full-thickness skin loss due to burn (third degree nos) of breastDeep necrosis of underlying tissues due to burn (deep third degree) of breast, without mention of loss of a body part | T21.31XA | Burn of third degree of chest wall, initial encounter |
T21.71XA | Corrosion of third degree of chest wall, initial encounter | ||
942.51 | Deep necrosis of underlying tissues due to burn (deep third degree) of breast, with loss of a body part | T21.31XA | Burn of third degree of chest wall, initial encounter |
959.19 | Other injury of other sites of trunk | ||
996.54 | Mechanical complication due to breast prosthesisNote: Breast prosthesis complication covered if the prosthesis was covered. | T85.41XA -T85.49XS | Mechanical complication of breast prothesis and implant (code range) |
996.69 | Infection and inflammatory reaction due to other internal prosthetic device, implant, and graftNote: Breast prosthesis complication covered if the prosthesis was covered. | T85.79XA | Infection and inflammatory reaction due to other internal prosthetic device, implants, and grafts |
V10.3 | Personal history of malignant neoplasm of breast | Z85.3 | Personal history of malignant neoplasm of breast |
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