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.