Breast Reconstructive Surgery After Mastectomy
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Governs coverage of breast reconstruction and related procedures when performed in connection with medically necessary mastectomy for Blue Cross Blue Shield of Kansas members; affects providers submitting claims and seeking prior authorization under member contracts.
Section C removed and replaced; the prior exclusions language for services 'provided directly for or relative to cosmetic surgery or reconstructive surgery [of the breast are not covered] except when...' was removed and replaced with a brief statement that breast reconstructive surgery may be covered under other provisions of the member's contract.
Textured implants identified in an FDA market withdrawal were added as a covered reason for revision/removal/replacement when they cause persistent symptoms after incision healing.
Coverage Criteria
Covered indications
Covered when ALL of the following are met:
Applies regardless of reason for mastectomy; applies to men and women
Not an exhaustive list
Contract requirements must be met for coverage of these events.
Policy language was revised effective 07-23-2024 to remove the former detailed Section C exclusions that listed cosmetic or reconstructive services not covered except in enumerated situations. That Section C language was replaced with a concise statement that breast reconstructive surgery may be covered under other provisions of the member's contract. This operational change clarifies that coverage for reconstructive or cosmetic revisions is governed by the member's specific contract terms and applicable mandates rather than the previous prescriptive exclusion text.
The revision also explicitly added textured implants identified in an FDA market withdrawal as a covered reason for revision/removal/replacement when they cause persistent symptoms after incision healing, aligning coding and coverage language with safety communications and prior updates.
The Women's Health Care and Cancer Rights Act (WHCRA) does not mandate coverage for revision of a completed breast reconstruction performed solely to improve appearance. Such cosmetic revisions are not required by federal WHCRA and therefore may not be covered; coverage for those procedures depends on the member's contract terms and benefit design. The policy notes the American Society of Plastic Surgeons guidance acknowledging that additional surgery to revise or improve reconstruction results may not be eligible for insurance coverage.
Coding and Procedure 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, or part thereof (List separately in addition to code for primary procedure). |
| 15771 | Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate. |
| 15772 | Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof. |
| 19316 | Mastopexy. |
| 19318 | Reduction mammaplasty. |
| 19325 | Mammaplasty, augmentation; with prosthetic implant. |
| 19328 | Removal of intact mammary implant. |
| 19330 | Removal of mammary implant material. |
Provider Actions and Requirements
Verify benefits — prior authorization may be required
Prior authorization of services may be required by the member's contract; verify benefits with Blue Cross and Blue Shield of Kansas Customer Service before scheduling or performing services.
Provider alert — follow mandates and member contract
State and federal mandates and the specific member contract language take precedence over this medical policy; confirm contract provisions and any required authorizations to avoid coverage denial.
Operative report requirements — document resection, defect, incisions, and flap details
Include clear, specific operative report documentation that details the size of resection and defect, incisions performed, the nature and size of any flap(s), and exactly how flaps are rotated or transposed.
- Document size of the resection and size of the resulting defect
- Describe incisions made
- Specify nature and size of flap(s)
- Explain how flap(s) are rotated or transposed
Mandates and contract precedence — verify coverage and obtain authorizations
State and federal mandates and the member's contract provisions supersede this policy; lack of contract coverage or failure to obtain required prior authorization per the member contract may result in claim denial.
- Verify applicable state/federal mandates and member contract terms before providing services
- Obtain prior authorization when required by the member's contract to reduce denial risk
Definitions
Background
The Women's Health Care and Cancer Rights Act of 1998 (WHCRA) requires group health plans that cover mastectomy to also cover all stages of breast reconstruction, surgery on the other breast for symmetry, prostheses, and treatment of physical complications such as lymphedema. WHCRA coverage applies regardless of whether the mastectomy was performed for cancer and applies to both men and women. Kansas statute 40-2,166 likewise mandates coverage in connection with a medically necessary mastectomy for reconstruction of the affected breast, surgery of the contralateral breast to achieve symmetry, and prostheses and physical complications in all stages of mastectomy.
Providers should verify member-specific contract language and prior authorization requirements because the policy and state/federal mandates operate alongside the member's benefits; operational coding and policy revisions (for example, additions related to textured implants) reflect updates to how reconstructive indications are handled within the coverage framework.
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