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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 4
Section 5.2
Post-Mastectomy Reconstructive Breast Surgery and Breast Prostheses
Issue Date:  October 7, 1982
Authority:  32 CFR 199.4(e)(8)(i)(D) and 10 USC 1079(a)(12)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-46, April 30, 2019
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
Breast reconstruction consists of mound reconstruction, nipple-areola reconstruction and areolar/nipple tattooing.
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.
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