Breast Reconstructive Surgery BREAST RECONSTRUCTIVE SURGERY HS-280. Policy Number: HS-280. Original Effective Date: 2/5/2015. Revised Date(s): N/A

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1 Easy Choice Health Plan, Inc. Harmony Health Plan of Illinois, Inc. Missouri Care, Inc. Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. WellCare Health Insurance of Illinois, Inc. WellCare Health Plans of New Jersey, Inc. WellCare Health Insurance of Arizona, Inc. WellCare of Florida, Inc. WellCare of Connecticut, Inc. WellCare of Georgia, Inc. WellCare of Kentucky, Inc. WellCare of Louisiana, Inc. WellCare of New York, Inc. WellCare of South Carolina, Inc. WellCare of Texas, Inc. WellCare Prescription Insurance, Inc. Windsor Health Plan Windsor Rx Medicare Prescription Drug Plan Breast Reconstructive Surgery Policy Number: Original Effective Date: 2/5/2015 Revised Date(s): N/A APPLICATION STATEMENT The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. Clinical Coverage Guideline page 1

2 DISCLAIMER The Clinical Coverage Guideline is intended to supplement certain standard WellCare benefit plans. The terms of a member s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member s benefit plan may contain specific exclusions related to the topic addressed in this Clinical Coverage Guideline. When a conflict exists between the two documents, the Member s Benefit Plan always supersedes the information contained in the Clinical Coverage Guideline. Additionally, Clinical Coverage Guidelines relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. Note: The lines of business (LOB) are subject to change without notice; consult for list of current LOBs. BACKGROUND The most common reason for breast reconstruction is to repair defects caused by breast cancer. Breast cancer is the second most frequently occurring cancer in the United States. A woman has a 12.5% lifetime risk of developing breast cancer and a 3.5% lifetime risk of dying from the disease. This risk generally increases with age. If she develops an invasive or in situ breast cancer, her risk of developing a second cancer in either breast increases by 0.5 to 1.0% per year. Approximately 5% to 10% of breast cancers are believed to be inherited, and as many as half of these are related to two breast cancer susceptibility genes, BRCA1 and BRCA2. Although uncommon, breast cancer also occurs in men, accounting for less than 1% of all breast cancers. Many women find that surgical reconstruction of the missing breast is an essential component in their recovery from cancer. Similarly, reconstruction of the opposite breast to provide symmetry and balance is an integral part of this process. 1 Patients usually presents to the plastic surgeon s office with a history of prior diagnosis and/or treatment for breast cancer. Patients who have had breast cancer may have had only a biopsy of the mass, a lumpectomy, or a simple mastectomy (alone or with axillary lymph node sampling or removal). Any of these surgical treatments may have been supplemented with radiation treatment to the breast and/or regional lymph nodes. Other cancer related treatments may include a modified radical mastectomy, chemotherapy and/or radiation, which may have an effect on the reconstructive site. Expander / implant reconstruction is the most commonly performed technique in the United States for post-mastectomy breast reconstruction. 1,2 Non-cancerous breast deformities may occur in men or women and result from a variety of conditions including congenital errors, trauma, disease or aging. Some of the more common deformities that require breast reconstruction surgery include Poland s Syndrome and tuberous breast(s). 3 Reconstructive Surgery Options 1,4 According to the American Society of Plastic Surgeons (ASPS), the type of breast reconstruction surgery is dependent on the nature of the defect and the overall health of the patient. Various surgical techniques can be used for the treatment of malignant conditions. Mastectomies can be total or partial. Reconstruction of a surgical defect caused by the removal of a breast cancer can be done at the time that the cancer is removed (immediate reconstruction) or any time thereafter (delayed reconstruction). The timing may be dependent on the need for additional treatment for malignancy, including chemotherapy and/or radiation. Furthermore, mastectomies can be skin-sparing or not skin-sparing. Skin-sparing mastectomies are generally performed for smaller and less invasive breast cancers, and offer a better cosmetic result for immediate breast reconstruction. A lumpectomy is a surgical alternative to mastectomy and is almost always combined with subsequent radiation treatment. It is generally used for lesions that are less than 4 cm in size. However, some patients who undergo a lumpectomy still need reconstructive surgery because of the defect created during surgical removal. The defect can vary significantly due to the size of the original tumor, the shape of the incision and the side effects of radiation used after lumpectomy. Reconstruction of the breast mound itself will require the use of a breast implant, autologous tissue, or both. The choice of surgical technique will depend on many factors, including the nature of the defect, the amount of tissue available for reconstruction, the underlying musculature, and the radiation history. Other factors in the patient s history will impact these Clinical Coverage Guideline page 2

3 choices such as age, other diseases such as diabetes, and the use of nicotine. If a breast implant is used, there must be sufficient skin left on the chest wall after surgery to cover the implant and sufficient underlying muscle to support it. When this skin is tight or insufficient it can be expanded or stretched by use of a tissue expander prior to placing a permanent implant. The tissue expander is itself a temporary prosthesis and in its position beneath the skin and/or chest muscle will, over time, stretch the overlying tissue as saline is injected incrementally over weeks to months. Once expansion is complete, the expander is removed and a permanent implant can be put in its place at a second surgery. 1 The transverse rectus abdominus muscle (TRAM) flap is performed if a patient is not a candidate for tissue expansion and breast implant, or if the patient wishes to have only autologous tissue used. The TRAM flap can be either pedicled (using its inherent blood supply from a single artery and vein) or a free tissue transfer. The choice of performing a TRAM flap is dependent on the patient s overall health, the quality and quantity of the lower abdominal tissues, prior abdominal surgery, and smoking history. When a patient is at risk for flap complications from having a pedicled TRAM, delaying the TRAM flap or choosing free tissue transfer of the TRAM are options. In the delay procedure, the more dominant blood supply to the flap, the deep inferior epigastric artery, is ligated to increase blood from the deep superior epigastric artery. This procedure opens up small vessels in regions of the flap and makes the flap more hearty. The final surgery which is usually done one to three weeks later is less risky due to the artificially created more robust blood supply. The free TRAM tissue transfer involves completely disconnecting both blood supplies and reconnecting the more dominant deep inferior epigastric artery using microvascular techniques. Another local muscle flap is the latissimus dorsi muscle. This muscle, taken from the back and side of the patient with some overlying back skin, can be used to restore the breast or to cover an implant. Often the latissimus muscle alone is not adequate to create a breast mound and an implant must be used to achieve volume. This flap is a good choice for patients who are not TRAM candidates or those who wish to have an implant with a history of prior radiation. It can also be used as a secondary treatment when local complications on the chest wall require additional tissue. Other flap techniques that may be used for breast reconstruction are free tissue transfers including the superior gluteal flap, the lateral thigh flap, the deep inferior epigastric perforator (DIEP) flap, and the Rubens flap. These flaps are generally utilized only when the first line choices cannot be used. Skin sparing mastectomy (removal of breast tissue only) and immediate breast reconstruction may be appropriate for certain early stage cancers. Research has shown this to be effective and without increased risk of recurrence. Usually the opposite breast will require treatment to achieve balance and symmetry with the reconstructed side. This is undertaken at the time when the final mound configuration is mature and can include a lifting of the breast through skin removal (mastopexy) or complete reduction of both skin and breast tissue (reduction mammplasty). When the opposite breast remains smaller than the reconstructed breast placement of a small implant on this side can achieve symmetry as well. Follow-up care for breast reconstruction includes serial office visits for drain removal, suture removal, and assessment of wound healing during the first 4-6 weeks. If a tissue expander is being used, infusions of saline through an implanted port may take place as often as twice a week. Beyond that period, less frequent serial office visits are required to assess continued healing, appearance, scar maturation and patient satisfaction. Additional surgery for nipple reconstruction is usually delayed until the breast mound surgery has been finalized and the shape has matured. This surgery is usually undertaken as an outpatient surgery and can include local tissue rearrangement of grafts. Final pigmentation of the nipple can be achieved through tattoo techniques that adjust the color to the patient s opposite nipple or skin type. It is not uncommon for secondary surgery to be done to adjust the mound, the opposite breast or the final nipple reconstruction. These procedures are generally performed as an outpatient and result in high patient satisfaction from the overall result. Clinical Coverage Guideline page 3

4 National Comprehensive Cancer Network 5 The following are part of NCCN s 2014 Principles of Breast Reconstruction Following Surgery : Breast reconstruction may be an option for any woman receiving surgical treatment for breast cancer. All women undergoing breast cancer treatment should be education about breast reconstructive options as adapted to their individual clinical situation. However, breast reconstruction should not interfere with the appropriate surgical management of the cancer. The process of breast reconstruction should not govern timing or the scope of appropriate surgical treatment for this disease. The availability of or the practicality of breast reconstruction should not result in the delay or refusal of appropriate surgical intervention. An evaluation of the likely cosmetic outcome of lumpectomy should be performed prior to surgery. Oncoplastic techniques for breast conservation can extend breast-conserving surgical options in situations where the resection itself would likely yield an unacceptable cosmetic outcome. Application of these procedures may reduce the need for mastectomy and reduce the chances of secondary surgery for reexcision while minimizing breast deformity. Patients should be informed of the possibility of positive margins and potential need for secondary surgery, which could include re-excision segmental resection, or could require mastectomy with or without loss of the nipple. Oncoplastic procedures can be combined with surgery on the contralateral unaffected breast to minimize long-term asymmetry. For mastectomy, the possibility of reconstruction should be discussed and a preoperative evaluation of reconstructive options should be considered. Surgical options for breast reconstruction following mastectomy include: o Procedures that incorporate breast implants (e.g., tissue expander placement followed by implant placement, immediate implant placement); o Procedures that incorporate autologous tissue transplantation (e.g., pedicled TRAM flap, fat grafting, various microsurgical flaps from the abdomen, back, buttocks, and thigh) o Procedures that incorporate both breast implants and autologous tissue transplantation (e.g., latissimus dorsi flaps) Breast reconstruction following mastectomy can commence at the same time as mastectomy ( immediate ) or at some time following the completion of cancer treatment ( delayed ). In many cases, breast reconstruction involves a staged approach requiring more than one procedure such as: o Surgery on the contralateral breast to improve symmetry o Revision surgery involving the breast and/or donor site o Nipple and areola reconstruction and tattoo pigmentation Centers for Medicare and Medicaid Services 6 During recent years, there has been a considerable change in the treatment of diseases of the breast such as fibrocystic disease and cancer. While extirpation of the disease remains of primary importance, the quality of life following initial treatment is increasingly recognized as of great concern. The increased use of breast reconstruction procedures is due to several factors: A change in epidemiology of breast cancer, including an apparent increase in incidence; Improved surgical skills and techniques; The continuing development of better prostheses; and Increasing awareness by physicians of the importance of postsurgical psychological adjustment. Clinical Coverage Guideline page 4

5 Reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is considered a relatively safe and effective non-cosmetic procedure. Accordingly, program payment may be made for breast reconstruction surgery following removal of a breast for any medical reason. Program payment may not be made for breast reconstruction for cosmetic reasons. POSITION STATEMENT Applicable To: Medicaid Medicare Breast reconstruction surgery (for breast cancer surgeries) is considered medically necessary and includes, but may not be limited to: Insertion of breast implants Insertion of tissue expanders Mastopexy Nipple repigmentation (tattoo) Transverse rectus abdominis myocutaneous (TRAM) flap, deep inferior epigastric perforator (DIEP) flap, latissimus dorsi (LD) myocutaneous flap, superficial inferior epigastric artery (SIEA) flap, transverse upper gracilis (TUG) flapprofunda artery perforator flap, superior gluteal artery perforator (SGAP) flap or other free or pedicle flap procedures In addition, the following indications are considered medically necessary for breast reconstruction surgery (for breast cancer surgeries): 1. Following a medically necessary prophylactic mastectomy; OR, 2. Complications with or removal of breast implant(s) following a medically necessary mastectomy; OR, 3. Trauma (within 12 months post injury); OR, 4. Following a medically necessary mastectomy or lumpectomy resulting in a significant deformity*^ (e.g., for treatment of, or prophylaxis for, breast cancer; for chronic, severe fibrocystic breast disease [cystic mastitis]; or member is unresponsive to medical therapy). Additional criteria includes EITHER of the following: Breast reconstruction procedures performed on the diseased/affected breast (i.e., breast on which the mastectomy / lumpectomy was performed), including: o areolar and nipple reconstruction o areolar and nipple tattooing o autologous fat transplant (i.e., lipoinjection, lipofilling, lipomodeling) o breast implant removal and subsequent reimplantation o capsulectomy o capsulotomy o implantation of tissue expander o implantation of U.S. Food and Drug Administration (FDA)-approved internal breast prosthesis o oncoplastic reconstruction o reconstructive surgical revisions o tissue/muscle reconstruction procedures (e.g., flaps), including, but not limited to, the following : deep inferior epigastric perforator (DIEP) flap latissimus dorsi (LD) myocutaneous flap Ruben s flap superficial inferior epigastric perforator (SIEP) flap Clinical Coverage Guideline page 5

6 OR, superior or inferior gluteal free flap transverse rectus abdominus myocutaneous (TRAM) flap transverse upper gracilis (TUG) flap Breast reconstruction procedures (for breast cancer surgeries) performed on the non-diseased / unaffected / contralateral breast, in order to produce a symmetrical appearance, including: o areolar and nipple reconstruction o areolar and nipple tattooing o augmentation mammoplasty o augmentation with implantation of FDA-approved internal breast prosthesis when the unaffected breast is smaller than the smallest available internal prosthesis o autologous fat transplant (i.e., lipoinjection, lipofilling, lipomodeling) o breast implant removal and subsequent reimplantation when performed to produce a symmetrical appearance o breast reduction by mammoplasty or mastopexy o capsulectomy o capsulotomy o reconstructive surgery revisions to produce a symmetrical appearance * Breast reconstruction surgery is applicable to males and females. ^ A diagnosis of breast cancer is not required at all times and the timing of reconstructive services is not a factor in coverage. Breast reconstruction surgery to correct breast asymmetry is not considered medically necessary when performed for non-medically necessary cosmetic reasons. Breast Reconstruction Surgery for Non-Cancerous Breasts Breast reconstruction surgery for non-cancerous breasts is considered medically necessary for the following conditions: Congenital deformities of the breasts affecting the physical and psychological life of the member Deformities of the breast resulting from unintended injuries (i.e. accidents) Severe fibrocystic breast disease causing functional limitation on the life of the member Unintended complications of breast surgeries for non-malignant conditions causing pain, discomfort, irritation, bleeding, drainage, or complication affecting lactation Breast reconstruction surgery to correct complications from breast reduction surgeries (e.g., asymmetry) is not considered medically necessary when performed for non-medically necessary cosmetic reasons. Women s Health and Cancer Rights Act 7 The Women s Health and Cancer Rights Act (WHCRA) was signed into law on October 21, 1998 and contains protections for patients who elect breast reconstruction in connection with a mastectomy for breast malignancy. For plan participants and beneficiaries receiving benefits in connection with a mastectomy, plans offering coverage for a mastectomy must also cover reconstructive surgery and other benefits related to a mastectomy. Under WHCRA, mastectomy benefits must include coverage for: Reconstruction of the breast on which the mastectomy was performed (any type of reconstruction on either or both breast, affected and unaffected, including but not limited to the procedures listed above as Clinical Coverage Guideline page 6

7 medically necessary. The timing of reconstructive services is not a factor in coverage); Surgery and reconstruction of the other breast to produce a symmetrical appearance; Prostheses and physical complications at all stages of mastectomy, including lymphedemas. Under WHCRA, mastectomy benefits may be subject to annual deductibles and coinsurance consistent with those established for other benefits under the plan or coverage. CODING CPT * Codes Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (list separately in addition to code for primary procedure) Replacement of tissue expander with permanent prosthesis Removal of tissue expander(s) without insertion of prosthesis Suction assisted lipectomy, trunk (when specified as a breast reconstruction procedure following breast surgery) Mastopexy Reduction mammaplasty Mammaplasty, augmentation; without prosthetic implant Mammaplasty, augmentation; with prosthetic implant Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction Nipple/areola reconstruction Correction of inverted nipples Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion Breast reconstruction with latissimus dorsi flap, without prosthetic implant Breast reconstruction with free flap Breast reconstruction with other technique Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including of donor site Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, Including closure of donor site; with microvascular anastomosis (supercharging) Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM, double pedicle, including closure of donor site Open periprosthetic capsulotomy, breast Periprosthetic capsulectomy, breast Revision of reconstructed breast Preparation of moulage for custom breast implant Covered HCPCS Codes C1789 Prosthesis, breast (implantable) L8600 Implantable breast prosthesis, silicone or equal S2066 Breast reconstruction with gluteal artery perforator (GAP) flap, including harvesting of the flap, Microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral S2067 Breast reconstruction of a single breast with stacked deep inferior epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator (GAP) flap (s), including harvesting of the flap(s), microvascular transfer, closure of donor site (s) and shaping the flap into a breast, unilateral S2068 Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric Clinical Coverage Guideline page 7

8 artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral ICD-9-CM Procedure Codes Reduction mammaplasty Augmentation mammoplasty 85.6 Mastopexy Total reconstruction of breast Pedicle/muscle flap graft to breast Transposition of nipple Other mammaplasty Insertion/removal of breast tissue expander ICD-9-CM Diagnosis Code Malignant neoplasm of breast Secondary malignant neoplasm of breast Carcinoma in situ of breast Diffuse cystic mastopathy (severe fibrocystic disease) V10.3 Personal history of malignant neoplasm of breast V45.71 Acquired absence of breast (following medically necessary mastectomy or lumpectomy resulting in Significant deformity) Other specified disorders of breast (acquired deformity NOS) Acquired deformity of chest and rib (pectus excavatum) Pectus excavatum (congenital) Other anomalies of ribs and sternum (related to Poland s syndrome) Absence of muscle and tendon (related to Poland s syndrome) Specified anomalies of breast (hypoplasia breast) (congenital deformity NOS) V16.3 Family history of malignant neoplasm of breast (related to prophylactic mastectomy) V51.0 Encounter for breast reconstruction following mastectomy ICD-10 CM Diagnosis Codes C C Malignant neoplasm of nipple and areola, female breast C C Malignant neoplasm of central portion of female breast C C Malignant neoplasm of upper-inner quadrant of female breast C C Malignant neoplasm of lower-inner quadrant of female breast C C Malignant neoplasm of upper-outer quadrant of female breast C C Malignant neoplasm of lower-outer quadrant of female breast C C Malignant neoplasm of axillary tail of female breast C C Malignant neoplasm of overlapping sites of female breast C C Malignant neoplasm of unspecified site of female breast C C Malignant neoplasm of nipple and areola, male breast C C C C C C C C C C Malignant neoplasm of male breast C C C C C C C C Clinical Coverage Guideline page 8

9 C79.81 Secondary malignant neoplasm of breast D D05.12 Lobular, intraductal, and other unspecified carcinoma in situ of unspecified breast D D05.92 Lobular, intraductal, and other unspecified carcinoma in situ of unspecified breast N N60.19 Diffuse cystic mastopathy of breast N N64.82 Ptosis/hypoplasia of breast N64.89 Other specified disorders of breast N64.89 Other specified disorders of breast M95.4, M99.82, M99.88 Acquired deformity of chest and rib and other biomechanical lesion of thoracic region Q67.6 Pectus excavatum Q76.6 Other congenital malformations of ribs Q Q77.2 Congenital malformation of sternum, other congenital malformation of bony thorax Q79.8 Other congenital malformations of musculoskeletal system Q Q83.9 Congenital malformations of breast Z85.3 Personal history of malignant neoplasm of breast Z80.3 Family history of malignant neoplasm of breast Z Z90.13 Acquired absence of breast and nipple Z42.1 Encounter for breast reconstruction following mastectomy ICD-10 PCS Procedure Codes 0HBT0ZZ Excision of Right Breast, Open Approach 0HBT3ZZ Excision of Right Breast, Percutaneous Approach 0HBU0ZZ Excision of Left Breast, Open Approach 0HBU3ZZ Excision of Left Breast, Percutaneous Approach 0H0T07Z Alteration of Right Breast with Autologous Tissue Substitute, Open Approach 0H0T0JZ Alteration of Right Breast with Synthetic Substitute, Open Approach 0H0T0KZ Alteration of Right Breast with Nonautologous Tissue Substitute, Open Approach 0H0T37Z Alteration of Right Breast with Autologous Tissue Substitute, Percutaneous Approach 0H0T3JZ Alteration of Right Breast with Synthetic Substitute, Percutaneous Approach 0H0T3KZ Alteration of Right Breast with Nonautologous Tissue Substitute, Percutaneous Approach 0H0TX7Z Alteration of Right Breast with Autologous Tissue Substitute, External Approach 0H0TXJZ Alteration of Right Breast with Synthetic Substitute, External Approach 0H0TXKZ Alteration of Right Breast with Nonautologous Tissue Substitute, External Approach 0H0U07Z Alteration of Left Breast with Autologous Tissue Substitute, Open Approach 0H0U0JZ Alteration of Left Breast with Synthetic Substitute, Open Approach 0H0U0KZ Alteration of Left Breast with Nonautologous Tissue Substitute, Open Approach 0H0U37Z Alteration of Left Breast with Autologous Tissue Substitute, Percutaneous Approach 0H0U3JZ Alteration of Left Breast with Synthetic Substitute, Percutaneous Approach 0H0U3KZ Alteration of Left Breast with Nonautologous Tissue Substitute, Percutaneous Approach 0H0UX7Z Alteration of Left Breast with Autologous Tissue Substitute, External Approach 0H0UXJZ Alteration of Left Breast with Synthetic Substitute, External Approach 0H0UXKZ Alteration of Left Breast with Nonautologous Tissue Substitute, External Approach 0H0V07Z Alteration of Bilateral Breast with Autologous Tissue Substitute, Open Approach 0H0V0JZ Alteration of Bilateral Breast with Synthetic Substitute, Open Approach 0H0V0KZ Alteration of Bilateral Breast with Nonautologous Tissue Substitute, Open Approach 0H0V37Z Alteration of Bilateral Breast with Autologous Tissue Substitute, Percutaneous Approach 0H0V3JZ Alteration of Bilateral Breast with Synthetic Substitute, Percutaneous Approach 0H0V3KZ Alteration of Bilateral Breast with Nonautologous Tissue Substitute, Percutaneous Approach 0H0VX7Z Alteration of Bilateral Breast with Autologous Tissue Substitute, External Approach 0H0VXJZ Alteration of Bilateral Breast with Synthetic Substitute, External Approach 0H0VXKZ Alteration of Bilateral Breast with Nonautologous Tissue Substitute, External Approach 0H0T3JZ Alteration of Right Breast with Synthetic Substitute, Percutaneous Approach 0H0U3JZ Alteration of Left Breast with Synthetic Substitute, Percutaneous Approach Clinical Coverage Guideline page 9

10 0H0V3JZ 0H0T0JZ 0H0T0KZ 0H0T3JZ 0H0T3KZ 0H0U0JZ 0H0U0KZ 0H0U3JZ 0H0U3KZ 0HRT0JZ 0HRT0KZ 0HRT3JZ 0HRT3KZ 0HRU0JZ 0HRU0KZ 0HRU3JZ 0HRU3KZ 0HUT0JZ 0HUT0KZ 0HUT3JZ 0HUT3KZ 0HUU0JZ 0HUU0KZ 0HUU3JZ 0HUU3KZ 0H0V07Z 0H0V0JZ 0H0V0KZ 0H0V37Z 0H0V3JZ 0H0V3KZ 0HUV0JZ 0HUV3JZ 0HST0ZZ 0HSU0ZZ 0HSV0ZZ 0HRT07Z 0HRT0JZ 0HRT0KZ 0HRU07Z 0HRU0JZ 0HRU0KZ 0HRT075 0HRU075 0HRV075 0KXK0Z6 0KXK4Z6 0KXL0Z6 0KXL4Z6 0HRT076 0HRU076 0HRV076 Alteration of Bilateral Breast with Synthetic Substitute, Percutaneous Approach Alteration of Right Breast with Synthetic Substitute, Open Approach Alteration of Right Breast with Nonautologous Tissue Substitute, Open Approach Alteration of Right Breast with Synthetic Substitute, Percutaneous Approach Alteration of Right Breast with Nonautologous Tissue Substitute, Percutaneous Approach Alteration of Left Breast with Synthetic Substitute, Open Approach Alteration of Left Breast with Nonautologous Tissue Substitute, Open Approach Alteration of Left Breast with Synthetic Substitute, Percutaneous Approach Alteration of Left Breast with Nonautologous Tissue Substitute, Percutaneous Approach Replacement of Right Breast with Synthetic Substitute, Open Approach Replacement of Right Breast with Nonautologous Tissue Substitute, Open Approach Replacement of Right Breast with Synthetic Substitute, Percutaneous Approach Replacement of Right Breast with Nonautologous Tissue Substitute, Percutaneous Approach Replacement of Left Breast with Synthetic Substitute, Open Approach Replacement of Left Breast with Nonautologous Tissue Substitute, Open Approach Replacement of Left Breast with Synthetic Substitute, Percutaneous Approach Replacement of Left Breast with Nonautologous Tissue Substitute, Percutaneous Approach Supplement Right Breast with Synthetic Substitute, Open Approach Supplement Right Breast with Nonautologous Tissue Substitute, Open Approach Supplement Right Breast with Synthetic Substitute, Percutaneous Approach Supplement Right Breast with Nonautologous Tissue Substitute, Percutaneous Approach Supplement Left Breast with Synthetic Substitute, Open Approach Supplement Left Breast with Nonautologous Tissue Substitute, Open Approach Supplement Left Breast with Synthetic Substitute, Percutaneous Approach Supplement Left Breast with Nonautologous Tissue Substitute, Percutaneous Approach Alteration of Bilateral Breast with Autologous Tissue Substitute, Open Approach Alteration of Bilateral Breast with Synthetic Substitute, Open Approach Alteration of Bilateral Breast with Nonautologous Tissue Substitute, Open Approach Alteration of Bilateral Breast with Autologous Tissue Substitute, Percutaneous Approach Alteration of Bilateral Breast with Synthetic Substitute, Percutaneous Approach Alteration of Bilateral Breast with Nonautologous Tissue Substitute, Percutaneous Approach Supplement Bilateral Breast with Synthetic Substitute, Open Approach Supplement Bilateral Breast with Synthetic Substitute, Percutaneous Approach Reposition Right Breast, Open Approach Reposition Left Breast, Open Approach Reposition Bilateral Breast, Open Approach Replacement of Right Breast with Autologous Tissue Substitute, Open Approach Replacement of Right Breast with Synthetic Substitute, Open Approach Replacement of Right Breast with Nonautologous Tissue Substitute, Open Approach Replacement of Left Breast with Autologous Tissue Substitute, Open Approach Replacement of Left Breast with Synthetic Substitute, Open Approach Replacement of Left Breast with Nonautologous Tissue Substitute, Open Approach Replacement of Right Breast using Latissimus Dorsi Myocutaneous Flap, Open Approach Replacement of Left Breast using Latissimus Dorsi Myocutaneous Flap, Open Approach Replacement of Bilateral Breast using Latissimus Dorsi Myocutaneous Flap, Open Approach Transfer Right Abdomen Muscle, Transverse Rectus Abdominis Myocutaneous Flap, Open Approach Transfer Right Abdomen Muscle, Transverse Rectus Abdominis Myocutaneous Flap, Percutaneous Endoscopic Approach Transfer Left Abdomen Muscle, Transverse Rectus Abdominis Myocutaneous Flap, Open Approach Transfer Left Abdomen Muscle, Transverse Rectus Abdominis Myocutaneous Flap, Percutaneous Endoscopic Approach Replacement of Right Breast using Transverse Rectus Abdominis Myocutaneous Flap, Open Approach Replacement of Left Breast using Transverse Rectus Abdominis Myocutaneous Flap, Open Approach Replacement of Bilateral Breast using Transverse Rectus Abdominis Myocutaneous Flap, Open Approach Clinical Coverage Guideline page 10

11 0HRT077 0HRU077 0HRV077 0HRT078 0HRU078 0HRV078 0HRT079 0HRU079 0HRV079 0HRT07Z 0HRT0JZ 0HRT0KZ 0HRU07Z 0HRU0JZ 0HRU0KZ 0HX5XZZ 0KXH0ZZ 0KXH4ZZ 0KXJ0ZZ 0KXJ4ZZ 0HSWXZZ 0HSXXZZ 0H0T0ZZ 0H0T3ZZ 0H0TXZZ 0H0U0ZZ 0H0U3ZZ 0H0UXZZ 0H0V0ZZ 0H0V3ZZ 0H0VXZZ 0HMTXZZ 0HMUXZZ 0HMVXZZ 0HNT0ZZ 0HNT3ZZ 0HNT7ZZ 0HNT8ZZ 0HNTXZZ 0HNU0ZZ 0HNU3ZZ 0HNU7ZZ 0HNU8ZZ 0HNUXZZ 0HNV0ZZ 0HNV3ZZ 0HNV7ZZ 0HNV8ZZ 0HNVXZZ 0HNW0ZZ 0HNW3ZZ 0HNW7ZZ Replacement of Right Breast using Deep Inferior Epigastric Artery Perforator Flap, Open Approach Replacement of Left Breast using Deep Inferior Epigastric Artery Perforator Flap, Open Approach Replacement of Bilateral Breast using Deep Inferior Epigastric Artery Perforator Flap, Open Approach Replacement of Right Breast using Superficial Inferior Epigastric Artery Flap, Open Approach Replacement of Left Breast using Superficial Inferior Epigastric Artery Flap, Open Approach Replacement of Bilateral Breast using Superficial Inferior Epigastric Artery Flap, Open Approach Replacement of Right Breast using Gluteal Artery Perforator Flap, Open Approach Replacement of Left Breast using Gluteal Artery Perforator Flap, Open Approach Replacement of Bilateral Breast using Gluteal Artery Perforator Flap, Open Approach Replacement of Right Breast with Autologous Tissue Substitute, Open Approach Replacement of Right Breast with Synthetic Substitute, Open Approach Replacement of Right Breast with Nonautologous Tissue Substitute, Open Approach Replacement of Left Breast with Autologous Tissue Substitute, Open Approach Replacement of Left Breast with Synthetic Substitute, Open Approach Replacement of Left Breast with Nonautologous Tissue Substitute, Open Approach Transfer Chest Skin, External Approach Transfer Right Thorax Muscle, Open Approach Transfer Right Thorax Muscle, Percutaneous Endoscopic Approach Transfer Left Thorax Muscle, Open Approach Transfer Left Thorax Muscle, Percutaneous Endoscopic Approach Reposition Right Nipple, External Approach Reposition Left Nipple, External Approach Alteration of Right Breast, Open Approach Alteration of Right Breast, Percutaneous Approach Alteration of Right Breast, External Approach Alteration of Left Breast, Open Approach Alteration of Left Breast, Percutaneous Approach Alteration of Left Breast, External Approach Alteration of Bilateral Breast, Open Approach Alteration of Bilateral Breast, Percutaneous Approach Alteration of Bilateral Breast, External Approach Reattachment of Right Breast, External Approach Reattachment of Left Breast, External Approach Reattachment of Bilateral Breast, External Approach Release Right Breast, Open Approach Release Right Breast, Percutaneous Approach Release Right Breast, Via Natural or Artificial Opening Release Right Breast, Via Natural or Artificial Opening Endoscopic Release Right Breast, External Approach Release Left Breast, Open Approach Release Left Breast, Percutaneous Approach Release Left Breast, Via Natural or Artificial Opening Release Left Breast, Via Natural or Artificial Opening Endoscopic Release Left Breast, External Approach Release Bilateral Breast, Open Approach Release Bilateral Breast, Percutaneous Approach Release Bilateral Breast, Via Natural or Artificial Opening Release Bilateral Breast, Via Natural or Artificial Opening Endoscopic Release Bilateral Breast, External Approach Release Right Nipple, Open Approach Release Right Nipple, Percutaneous Approach Release Right Nipple, Via Natural or Artificial Opening Clinical Coverage Guideline page 11

12 0HNW8ZZ 0HNWXZZ 0HNX0ZZ 0HNX3ZZ 0HNX7ZZ 0HNX8ZZ 0HNXXZZ 0HQT0ZZ 0HQT3ZZ 0HQT7ZZ 0HQT8ZZ 0HQTXZZ 0HQU0ZZ 0HQU3ZZ 0HQU7ZZ 0HQU8ZZ 0HQUXZZ 0HQV0ZZ 0HQV3ZZ 0HQV7ZZ 0HQV8ZZ 0HQVXZZ 0HQY0ZZ 0HQY3ZZ 0HQY7ZZ 0HQY8ZZ 0HQYXZZ 0HRT07Z 0HRT0KZ 0HRT37Z 0HRT3KZ 0HRTXJZ 0HRU07Z 0HRU0KZ 0HRU37Z 0HRU3KZ 0HRUXJZ 0HRV07Z 0HRV0KZ 0HRV37Z 0HRV3KZ 0HRVXJZ 0HUT07Z 0HUT0JZ 0HUT0KZ 0HUT37Z 0HUT3JZ 0HUT3KZ 0HUT77Z 0HUT7JZ 0HUT7KZ 0HUT87Z Release Right Nipple, Via Natural or Artificial Opening Endoscopic Release Right Nipple, External Approach Release Left Nipple, Open Approach Release Left Nipple, Percutaneous Approach Release Left Nipple, Via Natural or Artificial Opening Release Left Nipple, Via Natural or Artificial Opening Endoscopic Release Left Nipple, External Approach Repair Right Breast, Open Approach Repair Right Breast, Percutaneous Approach Repair Right Breast, Via Natural or Artificial Opening Repair Right Breast, Via Natural or Artificial Opening Endoscopic Repair Right Breast, External Approach Repair Left Breast, Open Approach Repair Left Breast, Percutaneous Approach Repair Left Breast, Via Natural or Artificial Opening Repair Left Breast, Via Natural or Artificial Opening Endoscopic Repair Left Breast, External Approach Repair Bilateral Breast, Open Approach Repair Bilateral Breast, Percutaneous Approach Repair Bilateral Breast, Via Natural or Artificial Opening Repair Bilateral Breast, Via Natural or Artificial Opening Endoscopic Repair Bilateral Breast, External Approach Repair Supernumerary Breast, Open Approach Repair Supernumerary Breast, Percutaneous Approach Repair Supernumerary Breast, Via Natural or Artificial Opening Repair Supernumerary Breast, Via Natural or Artificial Opening Endoscopic Repair Supernumerary Breast, External Approach Replacement of Right Breast with Autologous Tissue Substitute, Open Approach Replacement of Right Breast with Nonautologous Tissue Substitute, Open Approach Replacement of Right Breast with Autologous Tissue Substitute, Percutaneous Approach Replacement of Right Breast with Nonautologous Tissue Substitute, Percutaneous Approach Replacement of Right Breast with Synthetic Substitute, External Approach Replacement of Left Breast with Autologous Tissue Substitute, Open Approach Replacement of Left Breast with Nonautologous Tissue Substitute, Open Approach Replacement of Left Breast with Autologous Tissue Substitute, Percutaneous Approach Replacement of Left Breast with Nonautologous Tissue Substitute, Percutaneous Approach Replacement of Left Breast with Synthetic Substitute, External Approach Replacement of Bilateral Breast with Autologous Tissue Substitute, Open Approach Replacement of Bilateral Breast with Nonautologous Tissue Substitute, Open Approach Replacement of Bilateral Breast with Autologous Tissue Substitute, Percutaneous Approach Replacement of Bilateral Breast with Nonautologous Tissue Substitute, Percutaneous Approach Replacement of Bilateral Breast with Synthetic Substitute, External Approach Supplement Right Breast with Autologous Tissue Substitute, Open Approach Supplement Right Breast with Synthetic Substitute, Open Approach Supplement Right Breast with Nonautologous Tissue Substitute, Open Approach Supplement Right Breast with Autologous Tissue Substitute, Percutaneous Approach Supplement Right Breast with Synthetic Substitute, Percutaneous Approach Supplement Right Breast with Nonautologous Tissue Substitute, Percutaneous Approach Supplement Right Breast with Autologous Tissue Substitute, Via Natural or Artificial Opening Supplement Right Breast with Synthetic Substitute, Via Natural or Artificial Opening Supplement Right Breast with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Supplement Right Breast with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic Clinical Coverage Guideline page 12

13 0HUT8JZ 0HUT8KZ 0HUTX7Z 0HUTXJZ 0HUTXKZ 0HUU07Z 0HUU0JZ 0HUU0KZ 0HUU37Z 0HUU3JZ 0HUU3KZ 0HUU77Z 0HUU7JZ 0HUU7KZ 0HUU87Z 0HUU8JZ 0HUU8KZ 0HUUX7Z 0HUUXJZ 0HUUXKZ 0HUV07Z 0HUV0JZ 0HUV0KZ 0HUV37Z 0HUV3JZ 0HUV3KZ 0HUV77Z 0HUV7JZ 0HUV7KZ 0HUV87Z 0HUV8JZ 0HUV8KZ 0HUVX7Z 0HUVXJZ 0HUVXKZ 0HHT0NZ 0HHT3NZ 0HHT7NZ 0HHT8NZ 0HHU0NZ 0HHU3NZ 0HHU7NZ 0HHU8NZ 0HHV0NZ 0HHV3NZ 0HHV7NZ 0HHV8NZ 0HHW0NZ 0HHW3NZ 0HHW7NZ 0HHW8NZ 0HHX0NZ Supplement Right Breast with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic Supplement Right Breast with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic Supplement Right Breast with Autologous Tissue Substitute, External Approach Supplement Right Breast with Synthetic Substitute, External Approach Supplement Right Breast with Nonautologous Tissue Substitute, External Approach Supplement Left Breast with Autologous Tissue Substitute, Open Approach Supplement Left Breast with Synthetic Substitute, Open Approach Supplement Left Breast with Nonautologous Tissue Substitute, Open Approach Supplement Left Breast with Autologous Tissue Substitute, Percutaneous Approach Supplement Left Breast with Synthetic Substitute, Percutaneous Approach Supplement Left Breast with Nonautologous Tissue Substitute, Percutaneous Approach Supplement Left Breast with Autologous Tissue Substitute, Via Natural or Artificial Opening Supplement Left Breast with Synthetic Substitute, Via Natural or Artificial Opening Supplement Left Breast with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Supplement Left Breast with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic Supplement Left Breast with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic Supplement Left Breast with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic Supplement Left Breast with Autologous Tissue Substitute, External Approach Supplement Left Breast with Synthetic Substitute, External Approach Supplement Left Breast with Nonautologous Tissue Substitute, External Approach Supplement Bilateral Breast with Autologous Tissue Substitute, Open Approach Supplement Bilateral Breast with Synthetic Substitute, Open Approach Supplement Bilateral Breast with Nonautologous Tissue Substitute, Open Approach Supplement Bilateral Breast with Autologous Tissue Substitute, Percutaneous Approach Supplement Bilateral Breast with Synthetic Substitute, Percutaneous Approach Supplement Bilateral Breast with Nonautologous Tissue Substitute, Percutaneous Approach Supplement Bilateral Breast with Autologous Tissue Substitute, Via Natural or Artificial Opening Supplement Bilateral Breast with Synthetic Substitute, Via Natural or Artificial Opening Supplement Bilateral Breast with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Supplement Bilateral Breast with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic Supplement Bilateral Breast with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic Supplement Bilateral Breast with Nonautologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic Supplement Bilateral Breast with Autologous Tissue Substitute, External Approach Supplement Bilateral Breast with Synthetic Substitute, External Approach Supplement Bilateral Breast with Nonautologous Tissue Substitute, External Approach Insertion of Tissue Expander into Right Breast, Open Approach Insertion of Tissue Expander into Right Breast, Percutaneous Approach Insertion of Tissue Expander into Right Breast, Via Natural or Artificial Opening Insertion of Tissue Expander into Right Breast, Via Natural or Artificial Opening Endoscopic Insertion of Tissue Expander into Left Breast, Open Approach Insertion of Tissue Expander into Left Breast, Percutaneous Approach Insertion of Tissue Expander into Left Breast, Via Natural or Artificial Opening Insertion of Tissue Expander into Left Breast, Via Natural or Artificial Opening Endoscopic Insertion of Tissue Expander into Bilateral Breast, Open Approach Insertion of Tissue Expander into Bilateral Breast, Percutaneous Approach Insertion of Tissue Expander into Bilateral Breast, Via Natural or Artificial Opening Insertion of Tissue Expander into Bilateral Breast, Via Natural or Artificial Opening Endoscopic Insertion of Tissue Expander into Right Nipple, Open Approach Insertion of Tissue Expander into Right Nipple, Percutaneous Approach Insertion of Tissue Expander into Right Nipple, Via Natural or Artificial Opening Insertion of Tissue Expander into Right Nipple, Via Natural or Artificial Opening Endoscopic Insertion of Tissue Expander into Left Nipple, Open Approach Clinical Coverage Guideline page 13

14 0HHX3NZ 0HHX7NZ 0HHX8NZ 0HPT0NZ 0HPT3NZ 0HPU0NZ 0HPU3NZ Insertion of Tissue Expander into Left Nipple, Percutaneous Approach Insertion of Tissue Expander into Left Nipple, Via Natural or Artificial Opening Insertion of Tissue Expander into Left Nipple, Via Natural or Artificial Opening Endoscopic Removal of Tissue Expander from Right Breast, Open Approach Removal of Tissue Expander from Right Breast, Percutaneous Approach Removal of Tissue Expander from Left Breast, Open Approach Removal of Tissue Expander from Left Breast, Percutaneous Approach *Current Procedural Terminology (CPT ) 2015 American Medical Association: Chicago, IL. REFERENCES 1. Practice parameters: breast reconstruction following diagnosis and treatment for breast cancer. American Society of Plastic Surgeons (ASPS) Web site. forbreastcancer.pdf. Published September Accessed January 15, Evidence-based clinical practice guideline: breast reconstruction with expanders and implants. American Society of Plastic Surgeons (ASPS) Web site. Published March Accessed January 15, Practice parameters: non-cancer related breast reconstruction. American Society of Plastic Surgeons (ASPS) Web site. Reconstruction.pdf. Published September Accessed January 15, Breast cancer treatment (PDQ). National Cancer Institute (NCI) Web site. Published November 25, Accessed January 15, NCCN clinical practice guidelines in oncology: breast cancer. National Comprehensive Cancer Network Web site. www. Published Accessed January 15, National coverage determination: breast reconstruction following mastectomy (140.2). Centers for Medicare and Medicaid Services Web site. Published January 1, Accessed January 15, Fact sheet: Women's Health and Cancer Rights Act. United States Department of Labor Web site. Accessed February 5, MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS Date Action 2/5/2015 Approved by MPC. New. Clinical Coverage Guideline page 14