1.0 CPT
PROCEDURE CODES
19160 - 19240, 19340 - 19499
(For post-mastectomy reconstruction surgery)
19316, 19318, 19324 - 19325 (For contralateral
symmetry surgery)
3.0 POLICY
3.1 Post-mastectomy breast reconstruction is covered
when following a medically necessary mastectomy.
3.2 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.
3.3 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.
3.4 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.
3.5 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.
3.6 U.S. Food and Drug Administration (FDA) approved
implant material and customized external breast prostheses are covered.
3.7 Breast Magnetic Resonance Imaging (MRI) to
detect implant rupture is covered. The implantation of the breast
implants must have been covered by TRICARE.
3.8 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:
3.8.1 Have insufficient
tissue expander or implant coverage by the pectoralis major muscle
and additional coverage is required; or
3.8.2 There is viable, but compromised or thin post-mastectomy
skin flaps that are at risk of dehiscence or necrosis; or
3.8.3 The infra-mammary fold and lateral mammary
folds have been undermined during mastectomy and re-establishment
of these landmarks are needed.