CPT Code Description

19328 Removal of intact mammary implant

19330 Removal of mammary implant material

19355 Correction of inverted nipples

19370 Open periprosthetic capsulotomy, breast

19371 Periprosthetic capsulectomy, breast

19380 Revision of reconstructed breast

COVERAGE RATIONALE


Indications for Coverage

If the member’s condition meets the Women’s Health and Cancer Rights (WHCRA) criteria, please refer to the policy titled Breast Reconstruction Post Mastectomy.

Criteria for a Coverage Determination as Reconstructive and Medically Necessary:

Removal of breast implants with capsulectomy/capsulotomy for symptomatic capsular contracture is considered reconstructive and medically necessary when the following criteria are met:

** Baker grade III or IV capsular contracture; Baker Grading System for Capsular Contracture

o Grade I – breast is soft without palpable thickening

o Grade II – breast is a little firm but no visible changes in appearance

o Grade III – breast is firm and has visible distortion in shape

o Grade IV – breast is hard and has severe distortion or malposition in shape; pain/discomfort may be associated with this level of capsule contracture (ASPS, 2005)

** Limited movement leading to an inability to perform tasks that involve reaching or abduction. Examples include retrieving something from overhead, combing one’s hair, reaching out or above to grab something to stabilize oneself.

Removal of a deflated saline breast implant shell is considered cosmetic and is not medically necessary unless the implants were done post-mastectomy. Refer to the policy titled Breast Reconstruction Post Mastectomy.

Correction of inverted nipples is considered reconstructive and medically necessary when one of the following criteria are met:

** Member meets the Women’s Health and Cancer Rights Act (WHCRA) criteria (refer to the policy titled Breast Reconstruction Post Mastectomy for details); or

** Documented history of chronic nipple discharge, bleeding, scabbing or ductal infection. Note: If the correction of congenital inverted nipples may be covered based on the state mandates or member specific benefit plan document. See Congenital Anomaly definition below.

Revision of a reconstructed (CPT Code 19380) breast is considered reconstructive and medically necessary when the original reconstruction was done for mastectomy or other covered health service.

Refer to the Applicable Codes section below for a list of codes that meet the criteria for a reconstructed breast. Breast reconstruction done for Poland Syndrome (see definition below) is reconstructive. Although no functional impairment may exist for the breast reconstruction for Poland Syndrome, this has been deemed reconstructive surgery.

Removal of a ruptured silicone gel breast implant is covered regardless of the indication for the initial implant placement.

Additional Information

Tissue protruding at the end of a scar (“dog ear”/standing cone), painful scars or donor site scar revisions must be reviewed to determine if the procedure meets reconstructive guidelines.

Coverage Limitations and Exclusions

Some states require benefit coverage for services that Oxford considers cosmetic procedures, such as repair of external congenital anomalies in the absence of a functional impairment. Please refer to member specific benefit plan document.

** Cosmetic breast procedures are excluded from coverage. Examples include but are not limited to:

o Replacement of an existing breast implant if the earlier breast implant was performed as a cosmetic procedure . (Replacement of an existing breast implant is considered reconstructive if the initial breast implant followed mastectomy. Refer to the Breast Reconstruction Post Mastectomy policy.)

o Breast reduction surgery that is determined to be a cosmetic procedure. This exclusion does not apply to breast reduction surgery which we determine is requested to treat a physiologic functional impairment or to coverage required by the Women’s Health and Cancer Right’s Act.

o Breast surgery only for the purpose of creating symmetrical breasts except when post mastectomy.

o Breast prosthetics or replacement following a cosmetic breast augmentation.

** Revision of a prior reconstructed breast due to normal aging does not meet the definition of a covered reconstructive health service.

DEFINITIONS

Congenital Anomaly: A physical developmental defect that is present at the time of birth, and that is identified within the first twelve months of birth. Functional/Physical Impairment: A physical/functional or physiological impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired, or delayed capacity to move, coordinate actions, or perform physical activities and is exhibited by difficulties in one or more of the following areas: physical and motor tasks; independent movement; performing basic life functions.

Poland Syndrome: A rare, nonfamilial anomalad of unknown cause. The components of the syndrome include absence of the pectoralis major muscle, absence or hypoplasia of the pectoralis minor muscle, absence of costal cartilages, hypoplasia of breast and subcutaneous tissue (including the nipple complex), and a variety of hand anomalies. The most common chest wall reconstructive procedure in Poland’s is rotation of the latissimus dorsi muscle to reconstruct the anterior chest wall deficiency and anterior axillary fold.

Note: Poland Syndrome does not include tuberous breasts or developmental breast asymmetry.

Sickness: physical illness, disease or Pregnancy. The term Sickness as used in this Certificate does not include mental illness or substance abuse, regardless of the cause or origin of the mental illness or substance abuse)