DraftBlue Cross Blue Shield - Rhode IslandPolicy N/A

Mastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays Mandates

Governs coverage requirements for mastectomy, breast reconstruction, prostheses, post-mastectomy home visits and mandated hospital stay durations for Commercial members in Rhode Island; indicates Medicare Advantage differences. Affects providers delivering mastectomy-related care to BCBSRI members.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays Mandates

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 2, 2026

Next Review DateJan 10, 2025

Key ActionObtain prior authorization for Medicare Advantage members and follow the web-based prior authorization policy for listed procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

48minimum in-hospital stay after mastectomy (hrs)

24minimum in-hospital stay after axillary node dissection (hrs)

No cost sharein-network mastectomy-related services — Commercial

Required/Recommendedprior authorization

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Coverage Criteria and Statutory Requirements

Statutory coverage requirements

Covered when meeting statutory requirements and applicable product rules

WHCRA mandated services: All stages of reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses; and treatment of physical complications at all stages of the mastectomy, including lymphedema.

Federal WHCRA applies to applicable group plans.

Rhode Island mandate for Commercial Products: Same services as WHCRA are covered and, for plans with effective dates on or after January 1, 2019, in‑network services related to mastectomy treatment (codes listed in the policy) are covered at no cost share for Commercial members.

Applies to Commercial Products; Rhode Island mandates do not apply to Medicare Advantage Plans.

Hospital stay mandate: Coverage for a minimum forty‑eight (48) hour hospital stay after a mastectomy and a minimum twenty‑four (24) hour stay after an axillary node dissection. If the patient is discharged earlier than these minimums (early discharge), coverage must include at least one home visit by a physician or registered nurse.48 hours after mastectomy; 24 hours after axillary node dissection

Home care services for early discharge are available but the plan's applicable cost sharing applies unless the service is otherwise mandated to be cost‑share exempt.

Rhode Island statutory mandates that require coverage of mastectomy-related services apply to Commercial Products but do not apply to Medicare Advantage plans. For Medicare Advantage members, plan administration follows applicable federal rules and the member’s plan documents; providers should expect that Medicare Advantage members remain subject to applicable cost-sharing and medical management programs rather than the state-mandated no-cost-share provisions.

This medical policy is provided for informational purposes only and is not a guarantee of payment. Coverage, benefits, and eligibility are determined by the member's subscriber agreement, member certificate, or employer agreement, which prevail over this policy; for member-specific benefit information contact the provider call center.

No internal medical necessity criteria are listed in this section of the policy.

Codes, Diagnosis and Hospital Stay Requirements

Surgery, therapy and prosthesis codes (covered per mandate)mixedCovered

11920	Tattooing of the nipple/areola (covered when part of reconstruction)
11921	Tattooing of the nipple/areola (covered when part of reconstruction)
11922	Tattooing of the nipple/areola (covered when part of reconstruction)
11971	Adjunctive procedures
19301-19307	Mastectomy and related breast surgery CPT range
19316-19350	Breast reconstruction CPT range
19357-19396	Breast reconstruction/implant related CPT range
97010-97016	Physical Therapy modalities
97022	Physical Therapy
97110-97140	Therapeutic procedures (note: 97140 with diagnosis I97.2)

1–10 of 14

1/2

Compression garments and devicesHCPCSCovered

A4465	Compression garment
A6518	Compression garment (New Code Effective 4/1/2025)
A6519	Compression garment (New Code Effective 4/1/2025)
A6520-A6523	Compression garment HCPCS range
A6528-A6529	Compression garment HCPCS range
A6565	Compression garment
A6568-A6569	Compression garment HCPCS range
A6574-A6582	Compression garment HCPCS range
A6588-A6589	Compression garment HCPCS range
A6593	Compression garment

1–10 of 13

1/2

Primary diagnosis codes required for therapy and garment claimsICD-10

C50.011-C50.929	Breast cancer primary diagnosis code range
I97.2	Post mastectomy lymphedema syndrome

Refer to Policy Statementmixed

No codes listed

inv-09: Minimum hospital stay after mastectomy

Minimum hospital stay after mastectomy>= 48 hours (minimum in-hospital coverage for Commercial members per R.I. statute)

Early discharge provisionIf in-patient care is < 48 hours, coverage must include at least one home visit by a physician or registered nurse

ApplicabilityMandated for Commercial Products (state statute RIGL 27-20-29.1); Rhode Island mandate does not apply to Medicare Advantage plans

inv-10: Minimum hospital stay after axillary node dissection

Minimum hospital stay after axillary node dissection>= 24 hours (minimum in-hospital coverage for Commercial members per R.I. statute)

Prior Authorization, Billing and Appeal Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for Medicare Advantage plans and is recommended for certain Commercial product procedures. Some surgical codes listed in this policy may require medical review if they are also included in the Prior Authorization via Web-Based Tool for Procedures.

Prior Authorization required for Medicare Advantage plans; recommended for some Commercial products.
Some surgery codes require medical review when listed in the Prior Authorization via Web-Based Tool for Procedures.

Prior Authorization

Prior Authorization via Web-Based Tool

Use the BCBSRI Prior Authorization via Web-Based Tool for Procedures to submit authorization requests and to identify which procedure codes require authorization. Refer to the related policy for the complete list of procedure codes subject to review.

Submit prior authorization requests through the web-based tool.
See the Prior Authorization via Web-Based Tool for Procedures policy for codes and the authorization process.

Regulatory and Policy Background

Federal law (the Women’s Health and Cancer Rights Act of 1998) and Rhode Island statute (R.I. Gen. Laws § 27-20-29) require coverage for breast reconstruction following mastectomy, procedures to achieve symmetry of the contralateral breast, provision of prostheses, and treatment of physical complications of mastectomy (including lymphedema). The state law also specifies minimum in-hospital coverage durations and provisions for home visits when early discharge occurs.

Definitions

inv-20: Mastectomy definition

Definition'Mastectomy' means the removal of all or part of a breast as used in the state statute (RIGL 27-20-29)

ScopeIncludes services covered under the statute such as reconstruction, symmetry surgery, prostheses, and treatment of physical complications

Notice requirementWritten notice of availability of such coverage must be delivered upon enrollment and annually thereafter

Publication and Revision History

2025-06publicationLatest

Provider Update published (June 2025)

2024-03publication

Provider Update published (March 2024)

2024-08publication

Provider Update published (August 2024)

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays Mandates

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 2, 2026

Next Review DateJan 10, 2025

Key ActionObtain prior authorization for Medicare Advantage members and follow the web-based prior authorization policy for listed procedures.

SourceLink

On This Page

Early discharge provisionIf in-patient care is < 24 hours after axillary node dissection, coverage must include at least one home visit by a physician or registered nurse

Decision authorityAny decision to shorten the minimum coverage must be made by the attending physician in consultation with and upon agreement by the patient

Documentation Required

Coding and Diagnosis Requirements

Include the required CPT/HCPCS codes, primary diagnosis codes, and appropriate modifiers on claims for therapy, prostheses, and garments to avoid denial. Specific code groups and diagnosis pairings are listed in the policy.

Physical and Occupational Therapy: CPT 97010-97016; 97022; 97110-97140; 97161-97168; 97530. Primary diagnosis codes: C50.011–C50.929 and I97.2. Note: CPT 97140 must be filed with diagnosis I97.2.
Breast Prosthesis HCPCS: A4280; L8000–L8039.
Compression Garments HCPCS (filed with primary diagnosis I97.2): A4465; A6518; A6519; A6520–A6523; A6528–A6529; A6565; A6568–A6569; A6574–A6582; A6588–A6589; A6593; E0676; L0970; S8420–S8429.
Follow related policies for appropriate use of modifiers and CMS guidelines for dispensing/replacement limits.

Note

Benefit Verification

Verify member-specific benefits and eligibility prior to rendering services. Benefits and coverage are determined by the member's subscriber agreement or employer contract and supersede this policy.

Check member eligibility and benefits with Provider Services or the provider call center.
HSA-qualified HDHPs: cost sharing applies after the deductible is satisfied unless otherwise mandated.

Denial Risk

Denial and Appeal Considerations

BCBSRI may conduct managed-care and medical-necessity reviews; denials may be appealed per applicable regulations. If services are denied as non-covered or not medically necessary, providers may not bill the member unless the member was informed and provided written consent to proceed at their own expense.

Managed-care and medical-necessity reviews may be conducted by the insurer.
Subscribers may appeal denials in accordance with Department of Health regulations.
Providers may not charge members for services determined non-covered or not medically necessary unless the member provided prior written agreement.

Denial Risk

Appeal Rights and Provider Protections

Protections under Rhode Island law prohibit plans from denying eligibility or penalizing providers to avoid Mastectomy Treatment requirements. Members aggrieved by denials under RIGL 27-20-29 may appeal under Department of Health rules; plans must provide notice to enrollees regarding these rights.

Plans may not deny or refuse enrollment solely to avoid compliance with mastectomy coverage requirements.
Plans may not penalize or reduce reimbursement to providers for care consistent with RIGL 27-20-29.
Members may appeal denials under the Department of Health regulations; plans must notify enrollees of this coverage and appeal rights.

2023-02publication

Provider Update published (February 2023)

2023-10publication

Provider Update published (October 2023)

2022-01publication

Provider Update published (January 2022)

2020-04publication

Provider Update published (April 2020)

2020-07publication

Provider Update published (July 2020)