Medical Policy Original Effective Date: Revised Date: Page 1 of 8

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1 Page 1 of 8 Disclaimer Description Coverage Determination Refer to the member s specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefit on all plans, or the plan may have broader or more limited benefits than those listed in this. Breast reconstruction after mastectomy is offered to women and men of all ages, and is an integral component of therapy for patients with breast cancer or who have elected to have a medically necessary prophylactic mastectomy. As described in this, breast reconstruction is a series of surgeries done following a mastectomy, either for cancer, as a prophylactic mastectomy for cancer risk, for benign disease, or accident/trauma. Breast reconstruction for mastectomy may be immediate (at the same time as the mastectomy) or delayed. The selection of reconstruction may be based on an assessment of cancer treatment, patient body habitus, smoking history, comorbidities and patient concerns. 1 This refers to breast reconstruction after mastectomy only. See MPM 2.2 for Breast Implant Removal and/or Replacement and Capsulectomy. See MPM 2.5 for Breast Reduction Mammaplasty for Symptomatic Breast Hypertrophy. See MPM for Prophylactic Mastectomy and Oophorectomy for Prevention of Cancer. See MPM 17.6 for Restorative/Reconstructive/Cosmetic Treatment and Surgery for information on chest wall deformity and breast augmentation. Prior Authorization is required. Logon to Pres Online to submit a request: Breast reconstruction following a medically necessary mastectomy is mandated coverage by the Women s Health and Cancer Rights Act of The following is an excerpt from the Act : 1. All stages of 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 physical complications of all stages of mastectomy, including lymphedemas; in a manner determined in consultation with the attending physician and the patient. Such coverage may be subject to annual deductibles and coinsurance provisions as may be deemed appropriate and as are consistent with those established for

2 Page 2 of 8 other benefits under the plan or coverage. 2 Exclusion Coding Cosmetic surgery performed primarily to improve appearance and self-esteem is not a covered benefit. The coding listed in this is for reference only. Covered and non-covered codes may be included in this list. CPT Codes Description 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 Replacement of tissue expander with permanent prosthesis Removal of tissue expander(s) without insertion of prosthesis Repair, complex, trunk; 1.1 cm to 2.5 cm Repair, complex, trunk; 2.6 cm to 7.5 cm Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure) Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area Each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure) Mastopexy Reduction mammaplasty Mammaplasty, augmentation; without prosthetic implant Mammaplasty, augmentation; with prosthetic implant Removal of intact mammary implant Removal of mammary implant material 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 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 closure 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

3 Page 3 of 8 CPT Codes Periprosthetic capsulectomy, breast Description Revision of reconstructed breast HCPCS Codes C1789 Q4100 Q4116 L8600 S2066 S2067 S2068 Prosthesis, breast (implantable) Skin substitute, not otherwise specified AlloDerm, per sq cm Implantable breast prosthesis, silicone or equal Description 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 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 Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral DESCRIPTION C C Malignant neoplasm of nipple and areola C Malignant neoplasm of nipple and areola, unspecified female breast C Malignant neoplasm of nipple and areola, right female breast C Malignant neoplasm of nipple and areola, left female breast C Malignant neoplasm of central portion of unspecified female breast C Malignant neoplasm of central portion of right female breast C Malignant neoplasm of central portion of left female breast C Malignant neoplasm of upper-inner quadrant of unspecified female breast

4 Page 4 of 8 DESCRIPTION C Malignant neoplasm of upper-inner quadrant of right female breast C Malignant neoplasm of upper-inner quadrant of left female breast C Malignant neoplasm of lower-inner quadrant of unspecified female breast C Malignant neoplasm of lower-inner quadrant of right female breast C Malignant neoplasm of lower-inner quadrant of left female breast C Malignant neoplasm of upper-outer quadrant of unspecified female breast C Malignant neoplasm of upper-outer quadrant of right female breast C Malignant neoplasm of upper-outer quadrant of left female breast C Malignant neoplasm of lower-outer quadrant of unspecified female breast C Malignant neoplasm of lower-outer quadrant of right female breast C Malignant neoplasm of lower-outer quadrant of left female breast C Malignant neoplasm of axillary tail of unspecified female breast C Malignant neoplasm of axillary tail of right female breast C Malignant neoplasm of axillary tail of left female breast C Malignant neoplasm of overlapping sites of unspecified female breast C Malignant neoplasm of overlapping sites of right female breast C Malignant neoplasm of overlapping sites of left female breast C Malignant neoplasm of unspecified site of unspecified female breast C Malignant neoplasm of unspecified site of right female breast C Malignant neoplasm of unspecified site of left female breast C C Malignant neoplasm of nipple and areola C Malignant neoplasm of nipple and areola, unspecified male breast C Malignant neoplasm of nipple and areola, right male breast C Malignant neoplasm of nipple and areola, left male breast C Malignant neoplasm of unspecified site of unspecified male breast C Malignant neoplasm of central portion of right male breast C Malignant neoplasm of central portion of left male breast C Malignant neoplasm of central portion of unspecified male breast C Malignant neoplasm of upper-inner quadrant of right male breast C Malignant neoplasm of upper-inner quadrant of left male breast C Malignant neoplasm of upper-inner quadrant of unspecified male breast C Malignant neoplasm of lower-inner quadrant of right male breast C Malignant neoplasm of lower-inner quadrant of left male breast

5 Page 5 of 8 DESCRIPTION C Malignant neoplasm of lower-inner quadrant of unspecified male breast C Malignant neoplasm of upper-outer quadrant of right male breast C Malignant neoplasm of upper-outer quadrant of left male breast C Malignant neoplasm of upper-outer quadrant of unspecified male breast C Malignant neoplasm of lower-outer quadrant of right male breast C Malignant neoplasm of lower-outer quadrant of left male breast C Malignant neoplasm of lower-outer quadrant of unspecified male breast C Malignant neoplasm of axillary tail of right male breast C Malignant neoplasm of axillary tail of left male breast C Malignant neoplasm of axillary tail of unspecified male breast C Malignant neoplasm of overlapping sites of right male breast C Malignant neoplasm of overlapping sites of left male breast C Malignant neoplasm of overlapping sites of unspecified male breast C Malignant neoplasm of unspecified site of right male breast C Malignant neoplasm of unspecified site of left male breast C79.81 Secondary malignant neoplasm of other specified sites C79.81 Secondary malignant neoplasm of breast D04.5 Carcinoma in situ of skin D04.5 Carcinoma in situ of skin of trunk D05.00 Lobular carcinoma in situ of breast D05.90 Unspecified type of carcinoma in situ of unspecified breast D05.00 Lobular carcinoma in situ of unspecified breast D05.01 Lobular carcinoma in situ of right breast D05.02 Lobular carcinoma in situ of left breast D05.10 Intraductal carcinoma in situ of unspecified breast D05.11 Intraductal carcinoma in situ of right breast D05.12 Intraductal carcinoma in situ of left breast D05.80 Other specified type of carcinoma in situ of unspecified breast D05.81 Other specified type of carcinoma in situ of right breast D05.82 Other specified type of carcinoma in situ of left breast D05.91 Unspecified type of carcinoma in situ of right breast D05.92 Unspecified type of carcinoma in situ of left breast N64.89 Other specified disorders of breast

6 Page 6 of 8 DESCRIPTION N65.0 Deformity and disproportion of reconstructed breast N65.0 Deformity of reconstructed breast N65.1 Deformity and disproportion of reconstructed breast N65.1 Disproportion of reconstructed breast T Complications of other transplanted organs and tissues T Skin graft (allograft) rejection T Skin graft (allograft) (autograft) failure T Skin graft (allograft) (autograft) infection T Other complications of skin graft (allograft) (autograft) T Unspecified complication of skin graft (allograft) (autograft) T85.41xA Mechanical complication of breast prosthesis and implant T85.49XA Other mechanical complication of breast prosthesis and implant, initial encounter T85.41XA Breakdown (mechanical) of breast prosthesis and implant, initial encounter T85.42XA Displacement of breast prosthesis and implant, initial encounter T85.43XA Leakage of breast prosthesis and implant, initial encounter T85.44XA Capsular contracture of breast implant, initial encounter T85.72xA Infect/inflm reaction due to oth internal prosth dev/grft T85.79XA Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter T85.72XA Infection and inflammatory reaction due to insulin pump, initial encounter T Corneal transplant infection T85.81xA - Oth complications of internal prosth dev/grft, NEC T85.83xA T85.81XA Embolism due to internal prosthetic devices, implants and grafts, not elsewhere T85.82XA Fibrosis due to internal prosthetic devices, implants and grafts, not elsewhere T85.83XA Hemorrhage due to internal prosthetic devices, implants and grafts, not elsewhere T85.84XA Pain due to internal prosthetic devices, implants and grafts, not elsewhere T85.85XA Stenosis due to internal prosthetic devices, implants and grafts, not elsewhere T85.86XA Thrombosis due to internal prosthetic devices, implants and grafts, not elsewhere

7 Page 7 of 8 DESCRIPTION T85.89XA Other specified complication of internal prosthetic devices, implants and grafts, not elsewhere T Other complications of corneal transplant T Unspecified complication of corneal transplant Z85.3 Personal history of malignant neoplasm Z85.3 Personal history of malignant neoplasm of breast Z Z90.13 Acquired absence of breast and nipple Z90.10 Acquired absence of unspecified breast and nipple Z90.11 Acquired absence of right breast and nipple Z90.12 Acquired absence of left breast and nipple Z90.13 Acquired absence of bilateral breasts and nipples Z40.01 Encntr for prophylc surg for risks related to malig neoplm Z40.01 Encounter for prophylactic removal of breast Z42.1 Encntr for plast/recnst surg fol med proc or healed injury Z42.1 Encounter for breast reconstruction following mastectomy Z Z44.32 Encounter for fit/adjst of external breast prosthesis Z44.30 Encounter for fitting and adjustment of external breast prosthesis, unspecified breast Z44.31 Encounter for fitting and adjustment of external right breast prosthesis Z44.32 Encounter for fitting and adjustment of external left breast prosthesis Z Encounter for adjustment or removal of right breast implant Z Encounter for adjustment or removal of left breast implant Z Encounter for adjustment or removal of unspecified breast implant Reviewed by: 1. John Finley, MD, PMG Plastic Surgery, Albuquerque, NM. October References: 1. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Breast Cancer. NCCN.org.V Accessed on the Internet. No change. Accessed Updated version Accessed Updated version V Accessed Updated Version I Centers for Medicare and Medicaid Services. The Women s Health and Cancer Rights Act. Title IX, Sec Required Coverage for Reconstructive Surgery Following Mastectomy. Accessed : Accessed No

8 Page 8 of 8 change. Accessed No change. Accessed No change. Accessed Website changed but information has not changed. Reform/HealthInsReformforConsume/downloads/WHCRA_Statute.pdf Approval Signatures: Clinical Quality Committee: Norman White MD Medical Director: Pedro Cardona MD Date: January 27, 2016 Publication : Original Benefit/Technology Alert effective date History: : Transition to : Annual review and revision : Biennial Review : Biennial Review : Review And Updated ICD : Annual Review : Annual Review. Removed ICD 9 codes This is intended to represent clinical guidelines describing medical appropriateness and is developed to assist Presbyterian Health Plan and Presbyterian Insurance Company, Inc. (Presbyterian) Health Services staff and Presbyterian medical directors in determination of coverage. The is not a treatment guide and should not be used as such. For those instances where a member does not meet the criteria described in these guidelines, additional information supporting medical necessity is welcome and may be utilized by the medical director in reviewing the case. Please note that all Presbyterian Medical Policies are available online at: