1.0 CPT
PROCEDURE CODES
19160 - 19240, 19340 - 19499
(For post-mastectomy reconstruction surgery)
19316, 19318, 19324 - 19325 (For contralateral
symmetry surgery)
4.0 POLICY
4.1 Post-mastectomy
breast reconstruction is covered when following a medically necessary mastectomy.
4.2 Payment
may be made for contralateral symmetry surgery (i.e., reduction
mammoplasty, augmentation mammaplasty, or mastopexy performed on
the other breast to bring it into symmetry with the post-mastectomy
reconstructed breast).
Note: Services related
to the augmentation, reduction, or mastopexy of the contralateral
breast in post-mastectomy reconstructive breast surgery are not
subject to the regulatory exclusion for mammaplasties performed
primarily for reasons of cosmesis.
4.3 Treatment of complications
following reconstruction (including implant removal) regardless
of when the reconstruction was performed, and complications that
may result following symmetry surgery, removal and reinsertion of
implants are covered. See
Chapter 4, Section 5.5.
4.4 External
surgical garments/mastectomy bras (those specifically designed as
an integral part of an external prosthesis) are considered medical
supply items and are covered in lieu of reconstructive breast surgery or
when reconstruction surgery has failed.
Note: Benefits are subject to two initial external surgical
garments/mastectomy bras and two replacement external surgical garments/mastectomy
bras per calendar year.
4.5 Breast prosthesis is limited
to the first initial device per missing body part. Requests for replacements
are subject to medical review to determine reason for replacement.
4.6 U.S. Food
and Drug Administration (FDA) approved implant material and customized
external breast prostheses are covered.
4.7 Breast Magnetic Resonance
Imaging (MRI) to detect implant rupture is covered. The implantation
of the breast implants must have been covered by TRICARE.
4.8 Alloderm®
(an acellular allograft) is a covered benefit, effective July 8,
2008, when used in a covered breast reconstruction surgery for women
who have any of the following indications:
4.8.1 Have insufficient tissue expander
or implant coverage by the pectoralis major muscle and additional
coverage is required; or
4.8.2 There is viable, but compromised
or thin post-mastectomy skin flaps that are at risk of dehiscence
or necrosis; or
4.8.3 The infra-mammary fold and
lateral mammary folds have been undermined during mastectomy and
re-establishment of these landmarks are needed.