3.1 Breast
reconstructive surgery, to include surgery performed to establish
symmetry, is covered to correct breast deformities related to a
verified congenital anomaly. The following are examples of congenital
anomalies that require breast reconstruction:
3.1.1 Amastia
(absence of the breast); athelia (absence of nipple); polymastia
(supernumerary breasts); polythelia (supernumerary nipples); tubular
breast deformity; Poland syndrome.
3.1.2 Congenital
hypoplasia of one breast and gigantomastia of the contralateral
breast, if the breast reduction meets medical necessity criteria
outlined in
Section 5.4.
3.1.3 Paucity
of breast tissue due to chest wall deformities.
Note: The intent of the law is to
allow coverage for reconstructive surgery to correct a congenital anomaly.
A congenital anomaly may be present at birth, but only manifest
later; e.g., at puberty. In these cases, documentation (i.e., photographs
and physical examination, etc.) to verify the anomaly may be required.