BlueCross and BlueShield of Montana Medical Policy/Codes
Mastopexy
Chapter: Surgery: Procedures
Current Effective Date: December 27, 2013
Original Effective Date: December 27, 2013
Publish Date: September 27, 2013
Description

Mastopexy (breast lift) is a plastic reconstruction performed to correct ptosis or drooping and sagging of the breast. Breast ptosis (pendulous breasts) occurs as a result of gravity and the loss of elasticity in the dermis layer of skin, due either to or as a result of:

  • Age,
  • Multiple pregnancies,
  • Dramatic weight loss, or
  • Loss of mass resulting from postpartum atrophy.

Ptosis has been graded and modified by numerous physicians. The most commonly used system is as follows:

  • Grade I: mild ptosis – nipple just below inframammary fold but still above the lower pole of breast.
  • Grade II: moderate ptosis – nipple further below inframammary fold but still with some lower pole tissue below nipple.
  • Grade III: severe ptosis – nipple well below inframammary fold and no lower pole tissue below nipple (the “Snoopy Nose” appearance).

Pseudoptosis: Inferior pole ptosis, with nipple at or above inframammary fold, usually observed in postpartum breast atrophy.

The object of mastopexy is to achieve a firmer and more youthful-appearing breast while minimizing visible scars. To achieve this end result, multiple procedures and modifications of the mastopexy technique have been suggested, including performed by endoscopic techniques and by laser surgery. If there is inadequate breast tissue to achieve the desired breast size, a saline-filled implant may be placed beneath the breast at the same time. This type of correction is considered as cosmetic (aesthetic) surgery, by reshaping a normal structure of the body, in this case the breast, to improve the patient's appearance.

This policy does not address the use of mastopexy when part of the operative treatment plan for breast reconstruction (reconstructive mammaplasty) and contralateral breast surgery following:

  • Specific techniques for breast cancer treatment, accidental injury or trauma, or
  • Prophylactic mastectomy for benign disease or cancer risk.
Policy

Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.  Members and their providers have the responsibility for consulting the member's benefit plan or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern.

Coverage

Mastopexy, with or without breast implant insertion, including revisions of previous augmentation or mastopexy procedures done for cosmetic indications, is considered cosmetic and not eligible for benefit coverage.

For the associated policy related to insertion and/or removal of breast implants, please see Breast Implant, Removal and/or Insertion.

For assistance with mastopexy used in breast reconstruction management, refer to Reconstructive Mammaplasty and Contralateral Breast Surgery.

Rationale

Mastopexy, with or without breast implant insertion, is generally a cosmetic procedure. Breast mastopexy has no true medical indications and is performed primarily for aesthetic reasons. The exception to this is reconstructive mammaplasty and contralateral breast surgery when done for disease, prophylaxis, accidental injury or trauma. A mastopexy may be essential to achieving symmetry for those clinical conditions.

Benefit determinations should be based in all cases on the applicable contract language. If there are any conflicts between these guidelines and the contract language, the contract language will prevail.

2013 Update

A search of peer reviewed literature was performed through July 2013. The following is a summary of the literature evaluated.

Spear et al. published an 8 year retrospective review of patients undergoing revision of a previous augmentation or mastopexy of one practice. (9) The data collected included the original implant type (if applicable) and mastopexy type, new implant type (if applicable), location of revision, indication for revision, and interval from the original surgical procedure(s). Of the 20 patients’ records reviewed, there was a revision of 34 previously performed breast augmentations or mastopexies. Of the 20, 5 patients underwent a revision of a prior revision. Concurrently, a review of all primary augmentations or mastopexies was done on 40 patients. Indications for desired revisions included were capsular contracture, nipple ptosis/malposition, implant malposition, dissatisfaction of prior surgery, dissatisfaction of implant, scarring, breast ptosis, and patient preference. The average interval from prior original procedure to revision was 7 years.

No new clinical trial publications or any other additional information was identified that would change the coverage position of this medical policy.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy.  They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers.  Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes

Refer to the ICD-9-CM manual.

Procedural Codes: 19316, L8600
References
  1. Spear, S.L., Kassan, M. et al. Guidelines in concentric mastopexy. Plastic and Reconstructive Surgery (1990 June) 85(6): 961-6.
  2. Elsahy, N. Recent advances in the treatment of hypertrophy and ptosis of the breast. Journal of the Medical Association of Georgia (1991 November) 80(11) 627-30.
  3. Eaves, F.F., Bostwick, J., et al. Endoscopic techniques in aesthetic breast surgery. Augmentation mastectomy, biopsy, capsulotomy, capsulorrhaphy, reduction, mastopexy, and reconstructive techniques. Clinics in Plastic Surgery (1995 October) 22(4): 683-95.
  4. Flowers, R.S. and E.M. Smith. Flip-flap mastopexy. Aesthetic Plastic Surgery (1998 November-December) 22(6): 425-9.
  5. Eed, M.D. A new personal surgical procedure for breast reduction and lifting. Aesthetic Plastic Surgery (2000 May-June) 24(3): 206-11.
  6. de la Torre, J. Breast mastopexy. eMedicine (2002 May 7):1-14. Available on http://www.emedicine.com , accessed on 2004 June 18.
  7. Cehdeli, A. and R.M. Freund. Tear-drop augmentation mastopexy:  A technique to augment superior pole hollow. Aesthetic Plastic Surgery (2003 November-December) 27(6): 425-32.
  8. Reconstructive Breast Surgery/Management of Breast Implants (Archived). Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2012 January) Surgery: 7.01.22.
  9. Spear, S.L., Low, M., et al. Revision augmentation mastopexy: indications, operations, and outcomes. Annals of Plastic Surgery (2003 December) 51(6):540-6.
History
September 2013  New 2013 BCBSMT medical policy.
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Mastopexy