1.0 CPT PROCEDURE CODES
19160 - 19240, 19340 - 19499
(For post-mastectomy reconstruction surgery)
19316, 19318, 19324 - 19325
(For contralateral symmetry surgery)
2.0 DESCRIPTION
2.1 Breast reconstruction consists
of mound reconstruction, nipple-areola reconstruction and areolar/nipple
tattooing.
2.2 Mastectomy may refer
to complete, radical, modified radical, or partial (lumpectomy, tylectomy,
quadrantectomy, segmentectomy) procedures, with or without axillary
lymphadenectomy.
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.