Chapter 4
Section 5.6
Breast Reconstruction As
A Result Of A Congenital Anomaly
Issue Date: April 16, 1986
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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