Medical Review Criteria Breast Surgeries

Medical Review Criteria Breast Surgeries Effective Date: May 25, 2016 Subject: Breast Surgeries Policy: HPHC covers medically necessary breast surgeries including mastectomy, breast reconstruction, reduction mammoplasty, breast implant removal, and inverted nipple repair. Mastectomy (including prophylactic mastectomy) is covered when the PCP or attending provider determines that the procedure is medically necessary. 1 Post-mastectomy/post-lumpectomy breast reconstruction, and surgical and reconstructive procedures to the contralateral breast, are covered in accordance with the Women s Health & Cancer Rights Act of 1998 2 (i.e., to repair or restore appearance of one or both breasts, and/or for physical complications [e.g., lymphedema] of all stages of mastectomy or lumpectomy). Reconstructive procedures unrelated to mastectomy or lumpectomy are covered when HPHC determines a requested procedure is reasonable and medically necessary for the individual member. Removal of breast implants is covered when HPHC determines the procedure is reasonable and medically necessary for the individual member. (HPHC does not cover the removal of intact breast implants solely for a suspected benefit for prophylaxis against auto-immune disease, connective tissue disease or breast cancer, or because an intact implant has shifted as these indications are considered investigational and unproven.) Criteria used to review requests for gynecomastia surgery are described in HPHC s Gynecomastia Surgeries Medical Review Criteria. Authorization: Prior authorization is required for the following procedures requested for members enrolled in HPHC commercial (HMO, POS, or PPO) products: Breast Reconstruction Breast Implant Removal Inverted Nipple Repair 3 Breast Reduction/Reduction Mammoplasty 1 Prophylactic mastectomy, including total (simple) mastectomy or subcutaneous mastectomy, is typically considered medically necessary to prevent or reduce the risk of breast cancer in: Females with a BRCA1 or BRCA2 mutation confirmed by genetic testing Females with a first or second-degree relative (blood relative who shares at least 25-50% of the same genes) with a known BRCA1 or BRCA2 mutation; Males or females with a personal history of breast cancer; or Females with a personal history of ovarian cancer. 2 The Womens Health and Cancer Rights Act of 1998 (WHCRA) requires coverage for certain services related to mastectomy/lumpectomy, whether or not the surgery was covered by HPHC. (Nothing in the law limits WHCRA rights to women or to cancer patients.) Coverage includes reconstruction of the affected breast and nipple in a manner determined in consultation between the member and attending physician, surgical reconstruction of the unaffected breast (including reduction or augmentation of the non-diseased breast) to produce a symmetrical appearance, and breast prostheses. 3 Other nipple procedures are covered only when they are a medically necessary part of an authorized breast reconstruction procedure, and relevant are met. Breast Surgeries Page 1 of 6

Prior authorization is not required for mastectomy procedures including prophylactic mastectomy. Criteria: Procedure Criteria Breast Reconstruction Post-Mastectomy/Post-Lumpectomy Reconstruction including Breast Reduction, Augmentation, and/or Implant Use: Authorized when documentation confirms procedure is requested to repair or restore the appearance of one or both breasts, or for physical complications (e.g., lymphedema) after ANY of the following: Any stage of mastectomy, lumpectomy or excisional biopsy including evaluation and treatment of ANY of the following: Breast cyst Benign or malignant breast mass Aberrant breast tissue Duct lesion Nipple or areolar lesion Excision of chest wall tumor (including ribs) with or without plastic reconstruction. Reconstruction Unrelated to Mastectomy/Lumpectomy 4 : Reconstruction of the affected breast is authorized when documentation (including photographs*) confirms ANY of the following: Significant breast asymmetry (i.e., at least a 2-cup difference in breast size) in a female member who has reached physical maturity (age 16 years or older); Severe disfigurement resulting from surgical complications, trauma, disease, or Poland Syndrome. Reconstruction of the contra-lateral breast is NOT authorized unless documentation clearly demonstrates the medical necessity of the requested procedure. * Mailed or emailed photo documentation is required. Faxed photos of poor quality cannot be used to make a determination of medical necessity. Reconstruction After Removal of Breast Implants: Authorized when documentation confirms ANY of the following: Original implants were inserted following an authorized breast reconstruction procedure; Prior to the implant removal, the member met HPHC s Medical Review Criteria for breast reconstruction (above). Reconstruction after removal of breast implants in other situations, is considered cosmetic 5 and not covered (even if HPHC determines removal of the breast implant is medically necessary). 4 Coverage for medically necessary reconstructive surgery unrelated to mastectomy/lumpectomy is typically limited to one procedure per member per lifetime. Requests for subsequent procedures are reviewed and decided on a case by case basis. 5 Cosmetic surgery is surgery performed primarily to reshape or improve the patient's appearance. Most cosmetic services are not considered medically necessary, even if intended to improve an individual s emotional well-being or treat a mental health condition. Breast Surgeries Page 2 of 6

Procedure Breast Implant Removal Insertion of replacement implants is not authorized unless Breast Reconstruction criteria are met. Criteria Post-Mastectomy/Post-Lumpectomy Implant Removal: Authorized when documentation confirms procedure is requested to repair or restore the appearance of one or both breasts, or for physical complications after ANY stage of mastectomy, lumpectomy or excisional biopsy Implant Removal Unrelated to Mastectomy/Lumpectomy Removal of a silicone or saline breast implant is authorized when documentation confirms ANY of the following: Implant interferes with breast cancer screening Removal is needed to facilitate breast cancer treatment Removal is required to treat a persistent or recurrent infection (local or systemic) that is secondary to the breast implant, and refractory to medical management including antibiotics Removal is required to treat a capsular contracture (Baker Grade III- IV 6 ) that is causing pain, and is refractory to medical management. Removal of a ruptured silicone breast implant (intracapsular or extracapsular rupture) is authorized only when rupture is confirmed by diagnostic imaging (e.g., MRI or other conclusive study). Removal of a ruptured saline implant is not considered medically necessary in the absence of other complications. When criteria for the removal of a unilateral breast implant are met, removal of the contralateral implant is authorized only if the procedure independently meets implant removal criteria (above). Reduction Mammoplasty 7 Post-Mastectomy/Post-Lumpectomy Reduction Mammoplasty: Authorized when documentation confirms procedure is requested to repair or restore the appearance of one or both breasts, or for physical complications (e.g., lymphedema) after ANY of the following: Any stage of mastectomy, lumpectomy or excisional biopsy including evaluation and treatment of ANY of the following: Breast cyst Benign or malignant breast mass Aberrant breast tissue Duct lesion Nipple or areolar lesion Reduction Mammoplasty Unrelated to Mastectomy/Lumpectomy 6 Capsular contracture defined using Baker grades I through IV: Grade I : Breast is normally soft and looks natural. Grade II: Breast is a little firm but looks normal. Grade III: Breast is firm and looks abnormal. Grade IV: Breast is hard, painful, and looks abnormal. 7 Coverage for reduction mammoplasty other than post-mastectomy/lumpectomy reduction is typically limited to one procedure per member per lifetime. Requests for additional procedures are reviewed and decided on a case by case basis. Breast Surgeries Page 3 of 6

Procedure Criteria Authorized when documentation confirms the presence of severe breast hypertrophy in a female aged 16 years or older who has reached physical maturity and ALL the following criteria are met: 1. The member s physical symptoms are significant and persistent, and directly attributed to breast hypertrophy; 2. The member s symptoms have interfered with activities of daily living for at least six months, and are unrelieved despite conservative management (e.g., NSAIDS, support wear, physical therapy, optimal medical treatment); 3. The amount of breast tissue expected to be removed from each breast can reasonably be expected to improve the patient s symptoms, and meets or exceeds the amounts outlined in the Table for Reduction Mammoplasty Criteria (below).** In cases of breast asymmetry, bilateral reduction mammoplasty may be authorized when the amount of breast tissue expected to be removed from the larger breast meets criteria. **HPHC reserves the right to request the post-operative pathology report to confirm the amount of breast tissue that was removed from each breast. Table for Reduction Mammoplasty Criteria 8 The individual s body surface area (BSA) is calculated using the DuBois & DuBois Formula 9, BSA (m 2 ) = 0.007184 x (height 0.725 x weight 0.425 ) where height is in centimeters and weight is in kilograms. Member s body surface area (M 2) Weight (in grams) of Tissue to Be Removed 1.35-1.44 150 1.45-1.54 200 1.55-1.64 250 1.65-1.74 300 1.75-1.84 350 1.85-1.89 400 1.90-1.99 450 2.00-2.04 500 2.05-2.09 550 2.10-2.14 600 2.15-2.19 650 2.20-2.24 700 2.25-2.29 800 2.30-2.34 900 8 The constructed table is adapted from a study by Paul Schnur et al. Reduction Mammoplasty: Cosmetic or Reconstructive Procedure. The table uses the lower 15 percentile weight of breast tissue removed in relation to body surface area delineated by Schnur, and then rounds this to the nearest 50 grams. 9 An on line calculator is available at http://www-users.med.cornell.edu/~spon/picu/calc/bsacalc.htm Breast Surgeries Page 4 of 6

Member s body surface area (M 2) Weight (in grams) of Tissue to Be Removed 2.35-2.39 950 2.40-2.44 1050 2.45-2.49 1150 2.50-2.54 1250 2.55 1350 Coding: Codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive. 19316 Mastopexy 19318 Unilateral reduction mammoplasty 19318-50 Bilateral breast reduction mammoplasty 19324 Mammoplasty, augmentation; without prosthetic implant 19325 With prosthetic implant 19328 Removal of intact mammary implant 19330 Removal of mammary implant material 19355 Correction of Inverted Nipple 19340 Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction 19342 Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction 19350 Nipple/areolar reconstruction 19355 Correction of inverted nipples 19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion 19361 Breast reconstruction with latissimus dorsi flap, with or without prosthetic implant 19364 Breast reconstruction with free flap 19366 Breast reconstruction with other technique 19367 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; 19368 With microvascular anastomosis (supercharging) 19369 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site. 19370 Open periprosthetic capsulotomy, breast 19371 Periprosthetic capsulectomy, breast 19380 Revision of reconstructed breast 19396 Preparation of moulage for custom breast implant 19499 Unlisted procedure, breast Exclusions: HPHC does not cover listed breast surgeries when criteria above are not met. In addition, HPHC does not cover: Cosmetic procedures (e.g., mastopexy, correction of inverted nipple) that are not part of an authorized postmastectomy breast reconstruction procedure; Removal of intact breast implants solely for a suspected benefit for prophylaxis against auto-immune disease, connective tissue disease or breast cancer; Removal of an intact breast implant solely because it has shifted. Revisions: Approved by UMCPC: 5/25/16 Breast Surgeries Page 5 of 6

Revised: 9/02, 10/03, 10/04, 12/05, 1/06, 2/07, 2/08, 3/08, 4/09, 4/10, 5/11, 4/12, 4/13, 6/14, 6/15; 5/16 Initiated: 7/01 Summary of Changes Date Changes 5/16 Minor formatting edits. Updated references 6/15 Reformatted, minor language changes. Add coding profile. Add ASPS documents to references. Delete coverage for repair of inverted nipple unless part of an authorized post-mastectomy breast reconstruction procedure. Relevant Mandates: U.S. Women's Health and Cancer Right Act of 1998 Maine Title 24-A MRSA 4237 NH RSA 417-D:2-b References: Reduction Mammoplasty: ASPS Recommended Insurance Coverage Criteria for Third-Party Payers (accessed 5/18/15): http://www.plasticsurgery.org/documents/medical-professionals/healthpolicy/insurance/reduction_mammaplasty_coverage_criteria.pdf Breast Reconstruction for Deformities Unrelated to Cancer Treatment: ASPS Recommended Insurance Coverage Criteria for Third-Party Payers ): http://www.plasticsurgery.org/documents/medical- professionals/health-policy/insurance/breast-reconstruction-for-deformities-unrelated-to-cancer- Treatment.pdf Reduction mammoplasty - the sliding scale revisited. Ann Plastic Surg, Jan 1999; 42(1) 109-108. Reduction mammoplasty: cosmetic or reconstructive procedure. Schnur, Paul L, et al., "Reduction Mammoplasty: Cosmetic or Reconstructive Procedure?" Ann Plastic Surg. Sept 1991; 27 (3): 232-7. Hansen, J., Chang, S. Overview of breast reduction. In: UpToDate, Post, TW (ed), Waltham, MA, 2016. Nahabedia, M. Overview of breast reconstruction. In: UpToDate, Post, TW (ed), Waltham, MA, 2016. Chagpar, AB. Contralateral prophylactic mastectomy. In: UpToDate, Post, TW (ed), Waltham, MA, 2016. Breast Surgeries Page 6 of 6