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.

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:

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.

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.