BlueCross and BlueShield of Montana Medical Policy/Codes
Reconstructive and Contralateral Mammaplasty
Chapter: Surgery: Procedures
Current Effective Date: October 25, 2013
Original Effective Date: August 21, 2002
Publish Date: October 25, 2013
Revised Dates: February 15, 2007; March 1, 2010; June 20, 2013; October 11, 2013
Description

Reconstructive breast surgery (mammaplasty or mastoplasty) is defined as a series of surgical procedures that is designed to restore the normal appearance of the breast after surgery, disease, accidental injury, or trauma. Breast reconstruction is distinguished from purely cosmetic procedures by the presence of a medical condition, e.g., breast cancer or trauma, which leads to the need for breast reconstruction.

The most common indication for reconstructive breast surgery is a prior mastectomy; in fact, benefits for reconstructive breast surgery in these patients are a mandated benefit in many states.

In contrast, cosmetic breast surgery is defined as surgery designed to alter or enhance the appearance of a breast that has not undergone surgery, accidental injury, or trauma. Reduction mammaplasty is a common example of cosmetic breast surgery, but surgery to alter the appearance of a congenital abnormality of the breasts, such as tubular breasts, would also be considered cosmetic in nature.

There is a broadening array of surgical approaches to breast reconstruction. The most common is insertion of a breast implant, either a silicone gel-filled or saline-filled prosthesis. The implant is either inserted immediately at the time of mastectomy or sometime afterward in conjunction with the previous use of a tissue expander.

For some patients, reconstructive mammaplasty is accomplished in several staged procedures requiring two or three operations. Multiple techniques including tissue expanders, breast implants, regional or distant autologous tissue transfers/flaps, and/or reconstruction of the nipple-areolar complex (and nipple tattooing if applicable) may be required. The following is a listing, with definitions, of breast “flap” reconstructive procedures:

  1. Latissimus dorsi muscle flap utilizes donor tissue from the patient’s back that can be employed for reconstruction without significant loss of function. The latissimus flap can be moved into the breast defect, still attached to its blood supply under the arm pit (axilla). The latissimus flap is usually used to recruit soft-tissue coverage over an underlying breast implant. There are instances where enough volume can be recruited to reconstruct small breast without the placement of a breast implant;
  2. The abdominal flap used for breast reconstruction includes the TRAM (transverse rectus abdominis myocutaneous) flap, in which a portion of the abdomen tissue, including the skin, fat tissues, minor muscles, and connective tissues, is taken from the patient’s abdomen and transplanted onto the breast site once the breast cancer has been surgically removed;
  3. A DIEP (deep inferior epigastric perforators) flap is a type of breast reconstruction, in which abdominal muscle blood vessels, skin, and fat tissues are removed from the abdomen and transferred to the chest to reconstruct a breast without the sacrifice of any abdominal muscles OR
  4. The superficial inferior epigastric artery (SIEA) flap differs from the DIEP flap by utilizing tissue from the lower abdomen and takes a smaller section of skin and fat tissues to create the new breast. The blood vessels required for this flap come from the fatty tissue.

Nipple areola reconstruction or nipple tattooing may also be considered reconstructive breast surgery.

Since the purpose of reconstructive breast surgery is to restore the normal appearance of the breast, on some occasions, procedures are performed on the contralateral, normal breast to achieve symmetry. These procedures fall into the category of reconstructive breast surgery only when performed in conjunction with a contralateral mastectomy for cancer with associated reconstruction. Except for medically necessary reduction mammaplasty, these procedures are considered cosmetic in other circumstances. Contralateral breast surgery, the modification of the opposite, unaffected breast, may include the following services:

  • Reduction mammaplasty, a reconstruction of the breast to decrease in volume by excision of tissue;
  • Mastopexy (with or without breast implants) or breast lift, a reconstruction performed to correct ptosis or drooping and sagging of the breast;
  • Prophylactic mastectomy, not a procedure, per se; it is the rationale for the appropriateness to remove breast tissue in the absence of malignant disease and is also known as preventive mastectomy. It is typically bilateral, but may be performed unilaterally in a patient who has previously undergone a mastectomy in the opposite breast for an invasive cancer and is at risk for developing cancer in the remaining breast; OR
  • A combination of these procedures.

Frequently, additional surgical procedures are required to achieve the optimal final reconstructive results. These include excision of redundant tissue, repositioning of the implant, release of internal scar tissue, creation of inframammary fold, scar revision, and other tissue rearrangement.

The operative plan and specific techniques for breast reconstruction and contralateral breast surgery must be tailored to fit the patient's specific situation. This would include evaluating the terms of the cancer/pathology and the need for further treatment. Immediate reconstruction has the advantages of a shortened mastectomy incision, avoidance of mastectomy deformity, as well as multiple hospitalizations, multiple anesthesia, and postoperative courses. Delayed breast reconstruction following a mastectomy may be necessary when postoperative chemo- or radiation therapy is required. Reconstructive surgery may be performed immediately at the time of the initial surgery (mastectomy) or delayed for months or years.

The breast cancer management team includes, but is not limited to, the general, plastic or oncologic surgeon, radiologist, mammographer, radiation oncologist, medical oncologist, pathologist, breast-imaging specialist, nurses and nurse clinician, and medical social worker.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description 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, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Reconstructive and contralateral mammaplasty may be considered medically necessary if the surgery was based on disease, prophylaxis, accidental injury or trauma. The reconstructive surgery or partial mastectomy may include:

  • Insertion of an implant, in either single or staged procedures to the affected breast; OR
  • A partial mastectomy following an eligible breast reconstruction.

NOTE:  There is no time limit for coverage of reconstructive breast surgery and contralateral mammaplasty procedure(s) following an eligible full mastectomy or partial mastectomy.

Documentation must accompany any request for benefits or claims filed for breast reconstruction following partial mastectomy procedures and shall include:

  • History and physical examination notes, AND
  • Confirmatory lab and pathology reports, AND
  • Photodocumentation of the breast profile.

Procedures to achieve symmetry when post-mastectomy breast reconstruction has met the eligibility criteria may be considered medically necessary. These breast reconstructive techniques include, but are not limited to:

  • Immediate or delayed insertion of breast implants and with or without associated expanders; AND/OR
  • Autologous recoconstruction using the patient's own tissues (e.g., latissimus dorsi flap, transverse rectus abdominis myocutaneous flap, or free flap); AND/OR
  • Harvesting and grafting of autologous fat as a replacement for implants or to fill defects after breast conservation surgery; AND/OR
  • Revision of reconstructed breast; AND/OR
  • Reduction mammaplasty; AND/OR
  • Mastopexy with or without breast implants; AND/OR
  • Augmentation mammaplasty on the unaffected contralateral breast; AND/OR         
  • Nipple/areola reconstruction and nipple tattooing when the breast reconstruction is considered eligible for coverage.

Rationale

This policy was created in 2002 and updated periodically. A search of peer reviewed literature was completed through July 2013. The following is the key literature to date.

Most breast reconstruction patients are also breast cancer patients. Every year, a significant number of women with breast cancer must undergo mastectomy to treat their cancer effectively. Reconstructive breast surgery is considered medically necessary after a medically necessary mastectomy or after accidental injury or trauma. Except for medically necessary reduction mammaplasty (discussed in policy SUR716.012), these procedures would be considered cosmetic in other circumstances.

The evidence on breast reconstruction surgery consists primarily of case series, the majority of which are retrospective. A smaller number of prospective cohort studies have also been published. There is a lack of clinical trials, including a very limited number of randomized controlled trials (RCTs). The main outcomes that are important in breast reconstruction research are the cosmetic result, measures of psychosocial functioning, and rates of procedure-related morbidity.

Numerous case series have demonstrated improvements in psychosocial functioning for women undergoing breast reconstruction following mastectomy. For example, the Michigan Breast Reconstruction Outcomes Study (1), there was improvements in all subscales of the SF-36 health status questionnaire, and on the FACT-B scale, a breast-cancer specific health status instrument. These improvements were maintained for up to two years following surgery.

There is uncertainty in several areas of breast reconstruction. For women with breast cancer who are to receive radiotherapy post-mastectomy, the optimal timing and the preferred approach to breast reconstruction is controversial. Another important clinical question is the comparative effectiveness of different surgical approaches to reconstruction. The evidence for these 2 questions is reviewed below:

What is the optimal timing and approach to breast reconstruction in patients receiving radiotherapy post-mastectomy?

The potential advantages of immediate reconstruction are an improved cosmetic result, and avoiding the need to operate later on irradiated tissue. On the other hand, complications of reconstruction are higher if immediate reconstruction is followed by radiotherapy. Radiotherapy post-reconstruction has been shown to be an independent predictor of contractures, fat necrosis, and poor cosmetic outcomes. (2) Delayed reconstruction avoids the problem of radiation complications in the reconstructed breast. The disadvantages of this approach are the psychologic distress associated with waiting for reconstruction following mastectomy, and the difficulty of operating on previously irradiated tissue. (3, 4)

A Cochrane systematic review of immediate versus delayed breast reconstruction following mastectomy was published in 2011. (3) This review was confined to RCTs of immediate versus delayed surgery. Only one RCT from 1983 was identified, the results of which are probably not relevant to current clinical practice. As a result no conclusions could be drawn on immediate versus delayed reconstruction.

Winters et al. (5) published a systematic review that focused on the health-related quality of life outcomes following breast reconstruction surgery. These authors included articles that compared the outcomes of different types of reconstruction, or that compared immediate versus delayed reconstruction. They identified two RCTs, 11 prospective longitudinal studies, and 21 retrospective studies. The majority of the studies used general quality of life (QOL) instruments, such as the SF-36, rather than breast-specific QOL measures. The authors reported that the overall quality of the evidence was low. Most of the studies did not follow recommended methods for health-related quality of life research, and there was a high degree of variability in the reported outcomes. Combined analysis was not performed due to variations in study methodology and outcomes. Conclusions from this systematic review were that limitations of methodology precluded any meaningful conclusions on whether immediate or delayed reconstruction is the preferred approach.

The Michigan Breast Reconstruction Outcomes Study (1) was a prospective longitudinal study from 12 centers, which followed patients who had undergone breast reconstruction following mastectomy for up to 2 years. The main outcomes that were evaluated were psychosocial measures, including the SF-36 and the Functional Assessment of Cancer Therapy – Breast (FACT-B). A total of 287 women completed baseline surveys, and 173 completed the two-year follow-up for a response rate of 60.3%. The authors classified patients into the categories of immediate (n=116) versus delayed (n=57) reconstruction, and by the type of reconstructive surgery performed: pedicle transverse rectus abdominis myocutaneous (TRAM) flap (n=91), free TRAM (n=40) or expander/implant (n=42).

There was an improvement in QOL for all groups following reconstruction. At 2 years, the magnitude of improvement was greater for the immediate reconstruction group. Statistically significant improvements compared to baseline were noted for the SF-36 subscales of vitality, general mental health, role emotional, and social functioning; and for the FACT-B social well-being scale. In the delayed reconstruction group, there was a significant improvement in the FACT-B social well-being scale, but not for the subscales of the SF-36.

This study suggests that QOL outcomes may be better in immediate reconstruction versus delayed reconstruction. However, these conclusions are limited by the methodologic weaknesses of the study, which include a lack of formal comparisons between groups, a large number of dropouts at 2 years, and potential baseline differences in clinical characteristics of the groups that are compared.

What is the comparative efficacy of different surgical techniques for breast reconstruction?

There is a single RCT published comparing different techniques of breast reconstruction. (6) In this study, 87 women were randomized to 1 of 3 breast reconstruction techniques, and 75 women actually underwent 1 of the 3 procedures: Lateral thoracodorsal flap (n=16); Latissimus dorsi flap (n=30); or TRAM flap (n=29). At 6 months and 1 year following surgery, patients were asked about their satisfaction with the cosmetic result and the impact of the surgery on important areas of their lives. In addition, patients completed the SF-36 health status survey. At 6 months there were 56 responses (75%) to the survey and at 1 year there were 61 responses (81%). The majority of women reported a positive impact on major life areas and a positive change in overall health status. There were not significant differences among groups on any measure, except that the Latissimus dorsi group scored significantly lower on having problems with social situations compared to the other two groups. The results of this study support the conclusion that the benefit of breast reconstruction, in terms of cosmesis and quality of life, is roughly equivalent across different surgical techniques.

In the Barry et al. (4) systematic review, the authors evaluated whether implant-based approach or an autologous tissue approach led to better outcomes in patients receiving radiotherapy. Of all patients receiving radiotherapy (n=380), 216 underwent implant-based reconstruction and 164 underwent autologous reconstruction. There was no significant difference in overall morbidity between those receiving implant-based reconstruction and those receiving autologous reconstruction (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.47-1.62). However, for the subset of women who underwent both radiotherapy and immediate breast reconstruction, overall morbidity was less common in women undergoing autologous reconstruction (OR 0.20, 95% CI 0.11-0.39).

The Michigan Breast Reconstruction Outcomes Study (1) compared outcomes among patients. For most of the comparisons between types of surgeries, there were not significant differences noted. Patients who received delayed reconstruction with TRAM flap surgery had greater gains in body image compared with patients receiving implant-based reconstruction.

Clinical Practice Guidelines and Consensus Statements

The 2013 National Comprehensive Cancer Network (NCCN) guidelines (7) did not produce formal guidelines concerning breast reconstruction; however, they included a section within their breast cancer guideline that was titled “Principles of Breast Reconstruction Following Surgery”. The following summarizes the statements in this section:

  • The breast can be reconstructed using breast implants, autologous tissue or a combination of the two.
  • Breast reconstruction can be performed immediately following mastectomy or after a delay following mastectomy.
  • Skin-sparing mastectomy is probably equivalent to standard mastectomy in terms of local and regional recurrence. Skin sparing mastectomy should be performed by an experienced breast surgery team.
  • When post-mastectomy radiation is required:
  • Delayed reconstruction is generally preferred for autologous reconstruction
  • Immediate reconstruction is generally preferred for implant reconstruction
  • Selection of type of reconstruction is dependent on cancer treatment, body habitus, smoking history, comorbidities, and patient preferences.
  • An evaluation of the likely cosmetic outcome of lumpectomy should be performed prior to surgery.
  • Women who are not satisfied with the cosmetic outcome following completion of breast cancer treatment should be offered a plastic surgery consultation.

Summary

Breast reconstruction is intended for patients undergoing mastectomy for breast cancer, or who have an accidental injury or trauma to the breasts. For the general population of women undergoing mastectomy, the evidence supports the conclusion that breast reconstruction improves psychosocial outcomes, such as anxiety, social functioning, and perception of body image. Thus, breast reconstruction may be considered medically necessary when reconstruction is needed as a result of breast cancer, accidental injury, or trauma.

Important clinical questions remain concerning the optimal timing of breast reconstruction in women undergoing radiotherapy, and concerning which of the surgical approaches leads to better outcomes. For women undergoing radiotherapy following mastectomy, the evidence is not sufficient to determine whether immediate or delayed surgery is preferred. The evidence is also not sufficient to determine the comparative efficacy of different procedures. There is some evidence that an autologous tissue approach leads to better cosmetic outcomes in patients receiving radiotherapy, but this is not from high-quality evidence and is not a consistent finding across studies.

Breast implants can be used as part of breast reconstruction, or for cosmetic reasons. Local complications of breast implants are common, and may lead to explantation. The medical necessity of implant explantation is dependent on the type of implant, the indication for removal, and the original indication for implantation.

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

85.0, 85.20, 85.6, 85.31, 85.32, 85.33, 85.50, 85.51, 85.53, 85.54, 85.6, 85.7, 85.83, 85.84, 85.85, 85.87, 85.93, 85.94, 85.95, 85.99, 86.02, 174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.6, 174.8, 174.9, 198.81, 233.0, 610.1, 610.3, 611.0, 611.72, 611.79, 611.8, 709.2, 757.6, 757.8, 909.3, 996.54, 996.69, 996.79, 998.51, 998.59, 998.83, 998.9, V10.3, V16.3, V45.71, V50.1, V50.41, V51, V52.4

ICD-10 Codes

C50.011-C50.019, C50.211-C50.219, C50.311-C50.319, C50.411-C50.419, C50.511-C50.519, C50.611-C50.619, C50.811-C50.812, C50.911-C50.919, D05.01-D05.99, T85.41-T85.49, Z80.3, Z85.3, T85.71xA-T85.79xS, T85.81xA-T85.89xS, T85.698xA-T85.698xS, 0HBU0ZZ, 0HBV0ZZ, 0H0T07Z, 0H0T0JZ, 0H0T0KZ, 0H0T0ZZ, 0H0U07Z, 0H0U0JZ, 0H0U0KZ, 0H0U0ZZ, 0H0V07Z, 0H0V0JZ, 0H0V0KZ, 0H0V0ZZ, 0HRT0JZ, 0HRT075, 0HRT076, 0HRT077, 0HRT078, 0HRT079, 0HRU07Z, 0HRU075, 0HRU076, 0HRU077, 0HRU078, 0HRU079, 0HRV07Z, 0HRV075, 0HRV076, 0HRV077, 0HRV078, 0HRV079, 0HBT0ZZ, 0HBT3ZZ, 0HBU0ZZ, 0HBU3ZZ, 0HBV0ZZ, 0HBV3ZZ, 0H2TXYZ, 0H2UXYZ 

Procedural Codes: 11920, 11921, 11922, 15734, 15756, 15757, 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396, 19499, L8031, L8032, L8039, L8600, S2066, S2067, S2068
References
  1. Atisha D, Alderman AK, Lowery JC et al. Prospective analysis of long-term psychosocial outcomes in breast reconstruction: two-year postoperative results from the Michigan Breast Reconstruction Outcomes Study. Ann Surg 2008; 247(6):1019-28.
  2. Serletti JM, Fosnot J, Nelson JA et al. Breast reconstruction after breast cancer. Plast Reconstr Surg 2011; 127(6):124e-35e.
  3. D'Souza N, Darmanin G, Fedorowicz Z. Immediate versus delayed reconstruction following surgery for breast cancer . Cochrane Database Syst Rev 2011; (7):CD008674.
  4. Barry M, Kell MR. Radiotherapy and breast reconstruction: a meta-analysis. Breast Cancer Res Treat 2011; 127(1):15-22.
  5. Winters ZE, Benson JR, Pusic AL. A systematic review of the clinical evidence to guide treatment recommendations in breast reconstruction based on patient- reported outcome measures and health-related quality of life. Ann Surg 2010; 252(6):929-42.
  6. Brandberg Y, Malm M, Blomqvist L. A prospective and randomized study, "SVEA," comparing effects of three methods for delayed breast reconstruction on quality of life, patient-defined problem areas of life, and cosmetic result. Plast Reconstr Surg 2000; 105(1):66-74; discussion 75-6.
  7. National Comprehensive Cancer Network. Invasive Breast Cancer: principles of breast reconstruction following surgery. Version 3.2013. Available online at: http://www.nccn.org . Last accessed 2013 August 16.
  8. U.S. Department of Labor. 1998 Edition. “Your Rights After A Mastectomy. . . Women’s Health & Cancer Rights Act of 1998 (WHCRA).” Available online at http://www.dol.gov . Last accessed 2013 August 16.
  9. 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.
History
April 2012 Policy updated with literature review; references 1-5, 17 added. Policy statement amended to indicate both implant-based and autologous approaches to breast reconstruction are medically necessary. Policy archived by association.
February 2013 Removed Baker class III contractures and rupture of a saline implant criteria from the Not Medically Necessary Policy Statement.
June 2013 Policy formatting and language revised.  Split into two policies.  "Reconstructive and Contralateral Mammaplasty" and "Breast Implant, Removal and/or Insertion".  Previously titled "Reconstructive Breast Surgery/Management of Breast Implants".
October 2013 Document updated with literature review. The following was added to the list of breast reconstructive techniques for procedures to achieve symmetry as medically necessary: 1) immediate or delayed insertion of breast implants and with or without associated expanders; 2) autologous reconstruction using the patient's own tissues (e.g., latissimus dorsi flap, transverse rectus abdominis myocutaneous flap, or free flap); 3) harvesting and grafting of autologous fat as a replacement for implants or to fill defects after breast conservation surgery; 4) revision of reconstructed breast; and/or 5) nipple/areola reconstruction and nipple tattooing when the breast reconstruction is considered eligible for coverage. Rationale completely revised.
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Reconstructive and Contralateral Mammaplasty