CPT/HCPCS Codes
11920
Tattooing, intradermal introduction of insoluble opaque pigments to
correct color defects of skin, including micropigmentation; 6.0 sq cm or
less
11921 Tattooing, intradermal introduction of insoluble opaque
pigments to correct color defects of skin, including micropigmentation;
6.1 to 20.0 sq cm
11922 Tattooing, intradermal introduction of
insoluble opaque pigments to correct color defects of skin, including
micropigmentation; each additional 20.0 sq cm (List separately in
addition to code for primary procedure)
11970 Replacement of tissue expander with permanent prosthesis
11971 Removal of tissue expander(s) without insertion of prosthesis
19316 Mastopexy
19318 Reduction Mammoplasty (see Section B for other indications)
19324 Mammaplasty, augmentation; without prosthetic implant
19325 Mammaplasty, augmentation; with prosthetic implant
19340 Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
19342 Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction
19350 Nipple/areola reconstruction
19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion
19361 Breast reconstruction with latissimus dorsi flap, with or without prosthetic implant
19364 Breast reconstruction with free flap
19366 Breast reconstruction with other technique
19367
Breast reconstruction with transverse rectus abdominis myocutaneous
flap (TRAM), single pedicle, including closure of donor site;
19368
Breast reconstruction with transverse rectus abdominis myocutaneous flap
(TRAM), single pedicle, including closure of donor site; with
microvascular anastomosis (supercharging)
19369 Breast reconstruction
with transverse rectus abdominis myocutaneous flap (TRAM), double
pedicle, including closure of donor site
19370 Open periprosthetic capsulotomy, breast
19371 Periprosthetic capsulectomy, breast
19380 Revision of reconstructed breast
19396 Preparation of moulage for custom breast implant (not covered for Priority Health Medicaid)
Coverage Indications, Limitations, and/or Medical Necessity
Background:
Reduction mammaplasty is the surgical removal of a substantial portion of the breast, including the skin and underlying glandular tissue, until a clinically normal size is obtained.
Reduction mammaplasty is performed to reduce the size of the breast/breasts and:
help ameliorate symptoms caused by hypertrophy or
to reduce the size of a contralateral breast to bring it into symmetry with a breast reconstructed after cancer surgery.
Indications:
Reduction mammaplasty is considered medically necessary:
When the patient has significant symptoms that have interfered with normal daily activities despite conservative management for at least 6 months, including at least one of the following criteria:
History of back and/or shoulder pain which adversely affects activities of daily living (ADLs) unrelieved by, e.g.: conservative analgesia (e.g., such as NSAID, compresses, massage, etc.), supportive measures (e.g., such as garments, back brace, etc.), physical therapy, correction of obesity.
History of significant arthritic changes in the cervical or upper thoracic spine, optimally managed with medication and/or significant restriction of activity (e.g.: signs and symptoms of ulnar paresthesias evidenced by nerve conduction studies, cervicalgia, torticollis, or acquired kyphosis).
Signs and symptoms of: intertrigonous maceration and/or infection of the inframammary skin (e.g., hyperpigmentation, bleeding, chronic moisture, and evidence of skin breakdown refractory to dermatologic measures), or shoulder grooving with skin irritation (e.g., areas of excoriation and breakdown) by appropriate supporting garment.
AND:
The amount of breast tissue removed (by pathology report) is at least 400 grams per breast.
When the patient’s normal breast is reduced to achieve symmetry with a breast reconstructed after cancer surgery.
Limitations
Cosmetic surgery to reshape the breasts and surrounding tissue to improve appearance is not a Medicare benefit. The use of such CPT codes as 12034 and 12035, 14001, 15830, 15836, 15839, 15876 through 15879, and 19350 associated with reshaping will be considered part of (bundled into) the primary reduction mammaplasty procedure.
Indications of coverage must be met.
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
N/A
Breast Implant Removal
1. Removal of breast implants that were placed for reconstruction after mastectomy, injury, congenital asymmetry, or augmentation mammoplasty is a covered benefit for the following indications:
a. Implants with recurrent infection
b. Extruded implants
c. Baker Class IV Contracture, associated with severe pain, or
d. Breast cancer, new or recurrent (mastectomy and lumpectomy can be done with an implant in place, however, if a breast malignancy is discovered and the surgeon has requested coverage for removal, it is appropriate to provide coverage).
e. Implant rupture
2. Replacement/reinsertion of a breast implant is a covered benefit only if the original placement surgery would have been a covered benefit (e.g. if original prosthesis was placed due to cancer surgery, replacement of the prosthesis is a covered benefit; if original surgical indication was cosmetic augmentation, replacement of the prosthesis is not a covered benefit).
3. Removal of breast implants for the following conditions has been determined to not be medically necessary, and therefore, not a covered benefit:
a. Breast malposition/asymmetry
b. Baker Class II or III Contracture*
c. Patient anxiety related to the possibility of developing systemic disease, or anxiety related to the influence of breast implants on a current “autoimmune disease”. It has not been proven that individuals with breast implants are at an increased risk of developing a systemic disease, or that the implants influence the current status of the systemic disease.
4. Pain is frequently cited an indication for removal. The requesting physician should supply clinical information related to the degree of contracture (Baker classification*), or describe the etiology of the pain.
* Various systems have been used to classify breast contractures, but the most commonly used is the Baker classification. Four grades are described as follows:
Grade I Augmented breast feels soft as a normal breast
Grade II Augmented breast is less soft and implant can be palpated, but is not visible
Grade III Augmented breast is firm, palpable and the implant (or distortion) is visible
Grade IV Augmented breast is hard, painful, cold, tender and distorted
Reduction Mammoplasty
Unilateral and bilateral reduction mammoplasty is a covered benefit according to InterQual criteria.
For augmentation mammoplasty for asymmetry that is not cancer related see
C. Breast Reconstruction and Revision below. Limitations and Exclusions:
a. Mastopexy procedures (e.g. breast ptosis) are not a covered benefit. These procedures are considered to be cosmetic in nature and not performed to relieve pain due to macromastia.
b. Reduction mammoplasty for cosmetic purposes (to improve appearance) is not a covered benefit.
Breast Reconstruction and Revision
This section applies to reconstruction and revision for breast cancer. It would also apply to women at high risk of breast cancer who require prophylactic mastectomy.
Initial reconstruction can occur immediately after a mastectomy or be delayed until a patient undergoes radiation or chemotherapy or determines whether she wants breast reconstruction. Some women will opt for immediate breast reconstruction after mastectomy, while some may prefer delayed reconstruction. While some reconstructions can be completed in a single procedure, other techniques may require two or more surgical procedures for completion of the reconstructive process.
Further clarification of coverage for breast reconstruction and revision is outlined below.
1. Coverage for the breast affected by cancer, as well as for the breast(s) removed prophylactically (including bilateral prophylactic mastectomies).
The following are covered benefits:
a. Treatment for complications of breast reconstruction including cellulitis, other infections, and lymphedema.
b. Revisions required by surgical complications including infection, hematoma or seroma, or skin or flap necrosis.
c. Capsulotomies/capsulectomies for pain or contractures (see II. A. Breast Implant Removal above) for coverage criteria.
d. Prosthesis removal for pain, contractures, rupture, leakage or infection. (see II. A. Breast Implant Removal above) for coverage criteria.
e. Scar revisions are only covered if one of the following apply:
i. The scar resulted from a serious complication such as infection or wound dehiscence from surgery or post-op period
ii. The scar revision is an integral (not incidental) part of another covered procedure
Breast Reconstruction and Revision
This section applies to reconstruction and revision for breast cancer. It would also apply to women at high risk of breast cancer who require prophylactic mastectomy.
Initial reconstruction can occur immediately after a mastectomy or be delayed until a patient undergoes radiation or chemotherapy or determines whether she wants breast reconstruction. Some women will opt for immediate breast reconstruction after mastectomy, while some may prefer delayed reconstruction. While some reconstructions can be completed in a single procedure, other techniques may require two or more surgical procedures for completion of the reconstructive process. Further clarification of coverage for breast reconstruction and revision is outlined below.
1. Coverage for the breast affected by cancer, as well as for the breast(s) removed prophylactically (including bilateral prophylactic mastectomies).
The following are covered benefits:
a. Treatment for complications of breast reconstruction including cellulitis, other infections, and lymphedema.
b. Revisions required by surgical complications including infection, hematoma or seroma, or skin or flap necrosis.
c. Capsulotomies/capsulectomies for pain or contractures (see II. A. Breast Implant Removal above) for coverage criteria.
d. Prosthesis removal for pain, contractures, rupture, leakage or infection. (see II. A. Breast Implant Removal above) for coverage criteria.
e. Scar revisions are only covered if one of the following apply:
i. The scar resulted from a serious complication such as infection or wound dehiscence from surgery or post-op period
ii. The scar revision is an integral (not incidental) part of another covered procedure
Breast reconstruction surgery is also a covered benefit when incidental to disease and/or injury if:
a. a functional impairment is established and surgery is intended to correct the functional impairment OR
b. breast reconstructive surgery is performed to correct asymmetry of a breast when surgery has been performed on the other breast incidental to disease or injury.
Prior Authorization Requirements for Medicaid members (all of the following are required). The following documentation should be provided by the requesting physician:
a. Patient’s age
b. Physical description of the enlarged breast including symmetry, mass, induration and size
c. Medical history assessing the differential diagnosis including chronic diseases and medications
d. Previous work-up including mammogram and fine needle aspirate, where appropriate for evaluation of unilateral gynecomastia or masses.
e. High-quality original photographs for evaluation of the gynecomastia grade.
Digital Breast Tomosynthesis (DBT)
a. A screening DBT is considered medically necessary for individuals that have dense breasts.
b. A diagnostic DBT is considered medically necessary for individuals that have abnormal mammogram findings that require further imaging
Breast Reconstruction and Revision
Breast reconstruction surgery includes those surgical procedures which are intended to restore the normal appearance of the breast. This restoration occurs after surgery, accidental injury, or trauma.
Mastectomy for cancer is the most common reason women seek breast reconstruction, but other conditions such as severe post radiation changes or congenital deformities are other reasons that a woman may seek breast reconstruction.
Techniques of reconstruction include: tissue expansion, flap reconstruction, nipple areola reconstruction with subsequent implantation of a breast prosthesis. The tissue expander is a balloon-like device which is surgically placed under the chest tissue to create a breast-shaped space for the breast implant. Flap reconstruction allows for reconstruction using the patient’s own tissues. Donor flap sites include the back, lower abdomen, buttocks, or lateral hip region. For a latissumus flap the latissimus dorsimuscle is used. This muscle is frequently used for reconstruction surgery due to its large size and versatility. For a TRAM flap (transverse rectus abdominus musculocutaneous flap) excess abdominal tissue is tunneled under the skin from the lower abdomen to the chest and used to replace the breast tissue. For a free flap, tissue from other body sites (such as buttock or lateral thigh region) is transferred to the chest.
Although breast reconstruction is a cosmetic procedure, there are both Federal and Michigan state laws requiring health plans to cover breast reconstruction in certain defined circumstances. The federal and state requirements differ.
Pathological gynecomastia is associated with both androgen deficiency and estrogen excess. Both causes may be due to medications, diseases related to endocrinologic abnormalities, tumors, chronic disease, chromosomal abnormalities, familial disorders, and other miscellaneous conditions. While there is always a concern when a mass is present, breast cancer accounts for only 0.2 percent of all malignancies in male patients. A suspicious mass or lesion requires biopsy.
Gynecomastia Scale adapted from the McKinney and Simon, Hoffman and Kohn scales:
Grade I Small breast enlargement with localized button of tissue that is concentrated around the areola.
Grade II Moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest.
Grade III Moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present. Grade IV Marked breast enlargement with skin redundancy and feminization of the breast
Screening Mammography and Breast MRI
Screening Mammography
Screening mammography involves radiographic (X-ray) examination of the breast
performed at regular intervals, usually every 1 to 2 years, to detect breast cancer before it displays signs or symptoms. The goals of screening mammography for average risk women without any symptoms are to reduce breast cancer morbidity and mortality (illness and death). This can be accomplished by the accurate detection of the disease before it has metastasized (spread from the breast to another part of the body), when treatment can be less aggressive, and when the likelihood of long-term remission (decrease in symptoms) or cure is the highest.
According to the State of Michigan Insurance Code, breast cancer screening is defined as mammography using a standard 2-view per breast, low-dose radiographic examination of the breasts, and using equipment designed and dedicated specifically for mammography, in order to detect unsuspected breast cancer.
The Insurance Code goes on to define breast cancer diagnostic services as procedures intended to aid in the diagnosis of breast cancer, delivered on an inpatient or outpatient basis, including but not limited to mammogram, mammography, surgical breast biopsy, and pathologic examination and interpretation.
Breast MRI
Women with inherited mutations of the BRCA1 or BRCA2 gene have the highest risk of breast cancer. They make up 5 to 10 percent of women with breast cancer and are also at increased risk for ovarian cancer. The cumulative risk of breast cancer in women with BRCA1 mutations is 3.2 percent by the age of 30 years, 19.1 percent by the age of 40, 50.8 percent by the age of 50, 54.2 percent by the age of 60, and 85.0 percent by the age of 70; the cumulative lifetime risk for carriers of BRCA1 or BRCA2 mutations is 50 to 85 percent.
Screening mammography detects less than half of the breast cancers in mutation carriers, perhaps owing to young age, dense breasts, or pathological features of the tumor. Cancers in mutation carriers grow rapidly; half of them appear in the intervalbetween annual mammograms. The median size of such “interval cancers” is 1.7 cm, and half have spread to axillary lymph nodes by the time they are detected. It has been suggested that supplementing mammography with other imaging techniques, shorter screening intervals, or both may be valuable in mutation carriers. Liberman, L. “Breast Cancer Screening with MRI—What are the Data for Patients at High Risk?” New England Journal of Medicine, 351; 5, July 29, 2004, pp. 497-500.
D07.30 Carcinoma in situ of unspecified female genital organs
Z40.01 Encounter for prophylactic removal of breast
Z42.1 Encounter for breast reconstruction following mastectomy
Z42.8 Encounter for other plastic and reconstructive surgery
following medical procedure or healed injury
Z85.3 Personal history of malignant neoplasm of breast
Z90.10 – Z90.13 Acquired absence of breast and nipples
Z98.82 Breast implant status
N64.89 Other specified disorders of breast
T85.44xA – T85.44xS Capsular contracture of breast implant,
N65.0 Deformity of reconstructed breast
N65.1 Disproportion of reconstructed breast
T85.41xA – T84.49xS Mechanical complication of breast prosthesis and implant
T85.79xA – T85.79xS Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts
T85.828A-T85.828S Fibrosis due to other internal prosthetic devices, implants and grafts
T85.848A-T85.848S Pain due to other internal prosthetic devices, implants and grafts
T85.898A-T85.898S Other specified complication of other internal prosthetic devices, implants and grafts
Indications for Coverage
Breast reconstruction is covered for Members who have a Mastectomy with or without a diagnosis of cancer. Mastectomy includes partial (lumpectomy, tylectomy, quadrantectomy, and segmentectomy), simple, and radical.
This benefit does not include aspirations, biopsy (open or core), excision of cysts, fibroadenomas or other benign or malignant tumors, aberrant breast tissue, duct lesions, nipple or areolar lesions, or treatment of gynecomastia.
There is not a time frame in which the Member is required to have the reconstruction done post Mastectomy under the Women’s Health and Cancer Rights Act of 1998.
In accordance with Federal and State mandates, the following services are covered:
* Reconstruction of the breast on which the Mastectomy was performed
* Surgery and reconstruction of the other breast to produce a symmetrical appearance, including nipple tattooing
* Prosthesis (Implanted and/or external)
* Treatment of physical complications of Mastectomy, including lymphedema Various surgical techniques are used for breast reconstruction, including but not limited to:
* Insertion of FDA approved breast implants and tissue expanders
* Breast Implants and tissue expanders post Mastectomy with or without skin substitutes, approved by the FDA, including but not limited to: Alloderm, Allomax or FlexHD are a covered benefit
* Transverse Rectus Abdominus Myocutaneous Flap (TRAM)
* Latissimus Dorsi Flap (LD)
* Deep Inferior Epigastric Perforator (DIEP) Flap
* Gluteal Flap (GAP free flap)
Breast MRI
* Breast MRI is usually bilateral (CPT®77059) or can be unilateral (CPT®77058) in some after mastectomy, per physician request.
* MRI guided breast biopsy (CPT®19085) includes the imaging component. Additional lesions should be billed using CPT®19086.
* MRI Breast can be repeated at least 6 months after an MRI directed breast biopsy to document successful lesion sampling if histology is benign and nonspecific, equivocal or uncertain.
Breast MRI – Practice Notes
Although breast MRI has superior sensitivity in identifying new unknown malignancies, it carries a significant false positive risk when compared to mammogram and ultrasound. Incidental lesions are seen on 15% of breast MRI’s and increase with younger age The percentage of incidental lesions that turn out to be malignant varies from 3% to 20% depending on the individual population. Cancer is identified by breast MRI in only 0.7% of those with “inconclusive mammographic lesions
Breast Reconstruction
* CTA or MRA of the body part from which the free tissue transfer flap is being taken, can be performed for breast reconstruction preoperative planning.2,3
o For example, CTA (CPT®74175 and CPT®72191) or MRA (CPT®74185 and CPT®72198) of the abdomen and pelvis for Deep Inferior Epigastric Perforators (DIEP) flap
* There is currently insufficient evidence-based data to support the need for routine advanced imaging for TRAM flaps or other flaps performed on a vascular pedicle
CAD for Breast MRI
* The use of CAD with breast MRI is currently considered investigational, experimental, and/or unproven.
o 3D rendering codes (CPT®76376 or CPT®76377) should not be used in conjunction with code 0159T
Breast MRI is NOT Indicated
* Breast MRI should not be used to determine biopsy recommendations for suspicious or indeterminate lesion(s) that can be readily biopsied, either using imaging guidance or physical exam, such as palpable masses and microcalcifications.
* MRI should not be used for routine surveillance in individuals with history of breast cancer, unless there are physical exam, imaging findings, recurrent, or residual disease at the mastectomy site
Breast MRI Indications
* Breast MRI is indicated for breast augmentation, breast implants (saline or silicone), breast reconstruction, free injection, and capsular contracture to:
o Evaluate or confirm breast implant rupture when mammography or ultrasound is uninterpretable6
* If leakage is detected on MRI or any other modality, the implant(s) should be removed and no further surveillance MRI of the affected breast(s) is indicated.
* Surveillance for silent/asymptomatic rupture of silicone implants is considered investigational.
* Cigna does not cover surveillance MRI for breast implants if they were placed as part of purely cosmetic surgery.
* Annual breast MRI is indicated for high risk histologies:
o Atypical ductal hyperplasia (AD); Atypical lobular hyperplasia (ALH); Lobular carcinoma in situ (LCIS)
* Equivocal or Occult Findings
o Radiologist Report Recommendation for Breast MRI and one of the following:
* Inconclusive or conflicting findings on mammography or ultrasound of a lesion that is not a palpable mass
o A probably benign lesion on MRI (MRI BI-RADSTM 3) should undergo repeat MRI in 6 months.
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