CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Axillary Reverse Mapping for Prevention of Breast Cancer-Related Lymphedema

This policy describes Blue Cross Blue Shield Rhode Island's coverage stance on axillary reverse mapping/reverse lymphatic mapping performed during sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) to prevent breast cancer-related lymphedema and specifies applicability to Medicare Advantage and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyAxillary Reverse Mapping for Prevention of Breast Cancer-Related Lymphedema

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionDo not bill ARM using code 38999 for Medicare Advantage or Commercial products; services are considered not covered or not medically necessary.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredCoverage stance for ARM during SLNB or ALND

38999Unlisted CPT code considered not covered

≈38%ARM identification rate (systematic reviews)

2–3% / OR 0.20Reported lymphedema / pooled RCT effect

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Coverage Determinations

Coverage determinations

ARM during SLNB (Medicare Advantage): Axillary reverse mapping/reverse lymphatic mapping performed during sentinel lymph node biopsy (SLNB) to prevent lymphedema in individuals treated for breast cancer is not covered because the evidence is insufficient to determine improvement in net health outcome.

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ARM during ALND (Medicare Advantage): Axillary reverse mapping/reverse lymphatic mapping performed during axillary lymph node dissection (ALND) to prevent lymphedema in individuals treated for breast cancer is not covered because the evidence is insufficient to determine improvement in net health outcome.

[[5]]

ARM during SLNB (Commercial): Axillary reverse mapping/reverse lymphatic mapping performed during sentinel lymph node biopsy to prevent lymphedema in individuals treated for breast cancer is not medically necessary as the evidence is insufficient to determine improvement in net health outcome.

[[6]]

ARM during ALND (Commercial): Axillary reverse mapping/reverse lymphatic mapping performed during axillary lymph node dissection to prevent lymphedema in individuals treated for breast cancer is not medically necessary as the evidence is insufficient to determine improvement in net health outcome.

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There is no specific CPT code that represents axillary reverse mapping (ARM) or reverse lymphatic mapping. When providers report ARM using the unlisted procedure code 38999 (Unlisted procedure, hemic or lymphatic system), Blue Cross & Blue Shield of Rhode Island will consider that code not covered for Medicare Advantage and not medically necessary for Commercial Products when it is used to represent ARM.

This document does not list specific clinical exclusions for ARM. Coverage and benefits for any service, including ARM, are determined by the member’s subscriber agreement or employer agreement, which supersede this policy; providers should verify member-specific benefits with the provider call center prior to performing services.

For Commercial Products, axillary reverse mapping/reverse lymphatic mapping performed during sentinel lymph node biopsy (SLNB) or during axillary lymph node dissection (ALND) to prevent lymphedema is considered not medically necessary because the evidence is insufficient to demonstrate an improvement in net health outcome.

Services that are determined to be not medically necessary under this policy may be treated as non‑covered benefits. When a service is designated non‑covered or not medically necessary, providers may not be able to bill the member unless the member has been informed and has agreed in advance to accept financial responsibility.

Billing and Coding

Unlisted procedure code referencedCPTNot Covered

38999

Unlisted procedure, hemic or lymphatic system

Provider Requirements and Billing Guidance

Prior Authorization

Prior authorization is not applicable for this service per the policy.

Note

Benefit verification

For member-specific benefits and eligibility, contact the provider call center. Benefits are determined by the member's subscriber agreement and member certificate; those documents supersede this medical policy.

Contact provider call center for eligibility and benefits details
Benefits determined by subscriber/member certificate

Clinical Background

Surgery and radiotherapy for breast cancer are common causes of secondary lymphedema, a condition marked by accumulation of lymphatic fluid due to disruption of lymphatic drainage that can substantially impair quality of life and has no definitive cure. Axillary reverse mapping (ARM) is an intraoperative technique that attempts to identify and preserve arm‑draining lymphatics during axillary surgery with the goal of reducing postoperative lymphedema risk; however, current evidence has not established a clear net health benefit.

Key Definitions

inv-16: Axillary reverse mapping (ARM) — definition and typical techniques (dyes, ICG, radioisotopes)

DefinitionAxillary reverse mapping (ARM) — intraoperative technique involving subcutaneous administration of dyes, fluorescence agents (e.g., indocyanine green), or radioisotopes to visualize lymphatic drainage pathways of the arm and breast.

Typical visualization agentsBlue dye, indocyanine green (fluorescence), or radioisotopes are used to map lymphatic channels.

Purpose of mappingVisualization is intended to distinguish arm-draining lymphatics from breast-draining pathways to enable selective preservation of axillary nodes/lymphatics.

Adjunctive natureARM is adjunctive to SLNB and/or ALND and is performed intraoperatively to inform surgical preservation decisions.

inv-17: Lymphedema — definition and causes (secondary lymphedema from breast cancer treatment)

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyAxillary Reverse Mapping for Prevention of Breast Cancer-Related Lymphedema

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2024

Next Review DateN/A

Key ActionDo not bill ARM using code 38999 for Medicare Advantage or Commercial products; services are considered not covered or not medically necessary.

SourceLink

On This Page

Billing Rule

Billing note for unlisted code

When providers bill for axillary reverse mapping using unlisted procedure code 38999, Medicare Advantage will consider it not covered and Commercial products will consider it not medically necessary.

38999 — Unlisted procedure, hemic or lymphatic system

Denial Risk

Denial risk for ARM services

Claims for axillary reverse mapping (ARM) performed during sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) to prevent lymphedema are considered not covered / not medically necessary.

ARM during SLNB — Not covered
ARM during ALND — Not covered

Denial Risk

Member liability and denial risk

If services are determined to be not medically necessary or are non-covered benefits, providers may not charge the member unless the member has been informed in advance and agreed to accept financial responsibility. Refer to the provider participation agreement and the member's subscriber documents for applicable rules.

Providers must obtain member agreement in advance to bill member for non-covered services
Refer to participation agreement and subscriber documents

Lymphedema — accumulation of fluid due to disruption of lymphatic drainage; may be primary (congenital) but is most often secondary from acquired lymphatic damage.

Common causes in breast cancerSecondary lymphedema commonly results from breast cancer treatment including lymphadenectomy, axillary node dissection, and radiation therapy.

Risk modifiersRisk is increased by higher number of dissected/disrupted nodes, obesity/overweight, and postoperative infection; racial disparities in treatment patterns may affect risk.

Time course and prevalenceDevelopment can take months to years post-treatment; reported rates vary (up to ~13% after SLNB and as high as 77% after ALND in systematic reviews).

inv-18: Axillary reverse mapping (ARM) — additional definitional text and intent to identify/preserve arm-draining lymphatics

IntentARM is intended to identify and preserve lymphatic channels and nodes that drain the arm during axillary surgery to reduce postoperative lymphedema risk.

MechanismBy visualizing separate drainage pathways for arm versus breast, surgeons may avoid removal of lymph nodes/lymphatics that exclusively drain the arm.

Clinical contextARM is used during SLNB and/or ALND as an intraoperative mapping adjunct to inform selective preservation of arm-draining structures.

Regulatory noteARM itself is an adjunctive surgical technique; mapping agents (e.g., isosulfan blue, indocyanine green) may be subject to FDA regulation.