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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 4
Section 5.6
Breast Reconstruction As A Result Of A Congenital Anomaly
Issue Date:  April 16, 1986
Authority:  32 CFR 199.4(c)(2) and (e)(8)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  
1.0  CPT PROCEDURE CODES
19361 - 19369, 19499
2.0  DESCRIPTION
A congenital anomaly is a significant deviation from the normal form, existing at, and usually before, birth. It also refers to certain malformations or diseases which may be either hereditary or due to some influence occurring during gestation.
3.0  POLICY
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.
3.2  Augmentation and/or reduction of the collateral breast to correct congenital asymmetry when related to a congenital anomaly is covered.
3.3  Breast Magnetic Resonance Imaging (MRI) to detect implant rupture is covered. The implantation of the breast implants must have been covered by TRICARE.
4.0  EXCLUSION
Reconstructive breast surgery for incomplete or underdevelopment of breast not related to a verified congenital anomaly may not be cost-shared.
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