Coverage Policies

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If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 08/01/2012 Title: Breast Reconstruction
Revision Date: 05/01/2019 Document: BI366:00
CPT Code(s): 11920, 11921, 11922, 19303, 19305, 19306, 19307, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396, S8420, S8421, S8422, S8423, S8424, S8425, S8426, S8427, S8428, L8000, L8001, L8002, L8010, L8015, L8020, L8030, L8031, L8032, L8033, L8035, L8039
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    When QualChoice covered a mastectomy, all reconstruction following that mastectomy will be covered including;

a)    All stages of reconstruction of the breast on which the mastectomy had(s) been performed.

b)    Surgery and reconstruction of the opposite breast to produce a symmetrical appearance; and

c)     Prostheses and physical complications of mastectomy, including lymphedemas.

d)    The benefits will apply to deductibles and co-insurance.

2)    A patient who has had a mastectomy before coverage with QualChoice is eligible for the same coverage of reconstruction.  Since QualChoice has no records of the mastectomy being done, the provider needs to submit the appropriate diagnosis codes indicating the history of breast cancer and mastectomy. 

3)    This benefit does not apply to surgery following removal of a breast mass without mastectomy, even if the mass is cancerous (e.g. lumpectomy).

4)    This benefit does not apply to surgery to restore appearance after other forms of breast treatment (i.e. radiation therapy).

5)    Breast reconstruction for any other purpose is considered cosmetic.  Cosmetic procedures are not covered by most QualChoice plans.


Medical Statement

The Women’s Health and Cancer Rights Act of 1998 requires health plans that cover mastectomy also cover the following services if the insured elects breast reconstruction:

1)    Surgery and reconstruction of the breast on which the mastectomy has been performed;

2)    Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

3)    Prostheses and coverage for physical complications at all stages of a mastectomy, including lymphedemas.

 

If the original mastectomy was performed before coverage with QualChoice, the provider needs to submit the appropriate diagnosis codes reflecting a history of breast cancer and mastectomy.

For members who have had mastectomy for breast cancer, up to 2 prostheses per calendar year are allowed (for double mastectomy) and 2 mastectomy bras may be allowed per calendar year.

 

Codes Used In This BI:

 

11920

Skin tattooing 6.0 cm

11921

Skin tattooing 6.0 – 20 cm

11922

Skin tattooing > 20.cm

19324

Enlarge breast (code deleted 01-01-2021)

19325

Breast augmentation with implant

19328

Removal of intact breast implant

19330

Removal of ruptured breast implant, including implant contents

19340

Insertion of breast implant on same day of mastectomy

19342

Insertion or replacement of breast implant on separate day from mastectomy

19350

Breast reconstruction

19357

Tissue expander placement in breast reconstruction, including subsequent expansion(s)

19361

Breast reconstruction; with latissimus dorsi flap

19364

Breast reconstruction; with free flap

19366

Breast reconstruction (code deleted eff 01-01-2021)

19367

Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap

19368

Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis

19369

Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap

19370

Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy

19371

Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents

19380

Revision of reconstructed breast

19396

Design custom breast implant          

S8420

Gradient pressure aid (sleeve and glove combination), custom made

S8421

Gradient pressure aid (sleeve and glove combination), ready made

S8422

Gradient pressure aid (sleeve and glove combination), medium weight

S8423

 

Gradient pressure aid (sleeve and glove combination), custom made, heavy weight

S8424

Gradient pressure aid (sleeve), ready made

S8425

Gradient pressure aid (glove), custom made, medium weight

S8426

Gradient pressure aid (glove), custom made, heavy weight

S8427

Gradient pressure aid (glove), ready made

S8428

Gradient pressure aid (gauntlet), ready made

19303

Mastectomy, simple, complete

19305

Mastectomy, radical, including pectoral muscles, axillary lymph nodes

19306

Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes

19307

Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle

L8000

Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type

L8001

Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type

L8002

Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type

L8010

Breast prosthesis, mastectomy sleeve

L8015

External breast prosthesis garment, with mastectomy form, post mastectomy

L8020

Breast prosthesis, mastectomy form

L8030

Breast prosthesis, silicone or equal, without integral adhesive

L8031

Breast prosthesis, silicone or equal, with integral adhesive

L8032

Nipple prosthesis, prefabricated, reusable, any type, each

L8033

Nipple prosthesis, custom fabricated, reusable, any material, any type, each

L8035

Custom breast prosthesis, post mastectomy, molded to patient model

L8039

Breast prosthesis, not otherwise specified


Limits

1)    For members who have had mastectomy for breast cancer, 2 prostheses with mastectomy bras may be allowed per calendar year.

2)    Pressure gradient aids (S8420 – S8428) are not covered for any other diagnosis except for lymphedema as a complication of breast cancer and previous mastectomy.


Reference

Addendum:

Effective 09/01/2017:  Added diagnosis codes to eliminate need for PA if mastectomy not performed while covered by QualChoice.

Effective 07/01/2018:  Added codes for Gradient pressure aids (sleeves, gloves, gauntlets) (S8420 - S8428) that are covered for treatment of lymphedema that resulted as a complications of mastectomy for breast cancer.

Effective 03/01/2019:  For members who have had mastectomy for breast cancer, 2 prosthesis with mastectomy bras are considered medically necessary per calendar year.

Effective 05/01/2019: Added code Z42.1

Effective 9/1/2019: Clarified limits for prostheses and mastectomy bras.

Effective 01-01-2021: Deleted codes 19324 & 19366 and updated revised codes 19325, 19328, 19330, 19340, 19342, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371 & 19380 in the Codes Used in This BI and separated code ranges in the search box so they can be searchable. Also added codes 19303-19307 and L8000-L8002, L8010-L8039 to the search box and their descriptions to the codes used in this BI since they were never added but are in the claims statement.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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