CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Mastectomy — Treatment, Breast Reconstruction and Mastectomy Hospital Stays Mandates

Defines coverage requirements for mastectomy-related services including breast reconstruction, prostheses, lymphedema treatment, and minimum hospital stay/home visit mandates for Blue Cross & Blue Shield of Rhode Island members, with distinctions for Commercial products and Medicare Advantage plans.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMastectomy — Treatment, Breast Reconstruction and Mastectomy Hospital Stays Mandates

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization via the web-based tool for Medicare Advantage members and for select Commercial procedures as indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

48hminimum hospital stay after mastectomy for Commercial members

24hminimum hospital stay after axillary node dissection for Commercial members

WHCRAFederal mandate

RI 27-20-29State statutes

Required

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Coverage Criteria for Mastectomy-Related Services

Mandated Coverage Items

Covered when following mandated items apply

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

May be subject to annual deductibles and coinsurance consistent with other benefits under the plan.

Rhode Island State Mandate for Commercial Products: Mirrors WHCRA coverage and, for plans with effective dates on or after January 1, 2019, requires that in‑network services related to mastectomy treatment (as defined by the listed CPT/HCPCS codes) are covered at no cost share for Commercial members.

Does not apply to Medicare Advantage Plans.

Minimum Hospital Stay and Home Visit Requirement: Coverage for a minimum of 48 hours after mastectomy and 24 hours after axillary node dissection; if discharged earlier, at least one home visit by a physician or registered nurse is required.48 hours; 24 hours

Home care services are available for members who participate in the early discharge program; applicable plan cost sharing applies to home care services unless otherwise mandated.

The Rhode Island statutory mandates described in this policy apply to Commercial products but do not apply to Medicare Advantage Plans. For Medicare Advantage members, coverage and cost sharing follow the applicable Medicare Advantage plan rules and the member's subscriber agreement or employer agreement. (See Rhode Island mandate language and federal WHCRA references for the scope of required services under Commercial products.)

For Commercial members with plan effective dates on or after January 1, 2019, in-network services related to mastectomy treatment (including reconstruction, prostheses, symmetry procedures, and treatment of physical complications) are covered in accordance with the state mandate; Medicare Advantage members should follow the Medicare Advantage plan-specific coverage and authorization requirements.

Services that are designated as non-covered benefits in the member's subscriber agreement, member certificate, or employer agreement are excluded from coverage under this policy. Benefits and eligibility are determined by those governing documents, which supersede this medical policy. Providers should verify member-specific coverage before rendering services.

If services are determined to be not medically necessary under the terms of the plan, they may be denied and are not payable under this policy. Providers should not bill the member for services that are denied as not medically necessary unless permitted under the applicable plan provisions and the member has been informed as required.

Coding and Hospital Stay Requirements

Covered CPT Codes and PT codesCPTCovered

11920	Nipple/areola tattooing (covered as part of reconstruction)
11921	Nipple/areola tattooing
11922	Nipple/areola tattooing
11971	Breast reconstruction code listed
19301	Mastectomy/reconstruction related CPT code group (19301-19307 listed)
19302	See range 19301-19307
19307	See range 19301-19307
19316	Breast surgery/reconstruction (19316-19350 listed)
19350	Breast surgery/reconstruction (end of range 19316-19350)
19357	Breast reconstruction (19357-19396 listed)

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Covered HCPCS Codes (prostheses and compression garments)HCPCSCovered

A4280	Breast prosthesis (HCPCS)
L8000	Breast prosthesis (HCPCS)
L8039	Breast prosthesis (HCPCS)
A4465	Compression garment (filed with primary diagnosis 197.2 for post-mastectomy lymphedema)
A6520	Compression garment/device (new code effective 1/1/2024)
A6523	Compression garment/device (new code effective 1/1/2024)
A6528	Compression garment/device (new code effective 1/1/2024)
A6529	Compression garment/device (new code effective 1/1/2024)
A6565	Compression garment/device (new code effective 1/1/2024)
A6568	Compression garment/device (new code effective 1/1/2024)

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Diagnosis codes referencedICD-10

197.2	Primary diagnosis code for post-mastectomy lymphedema syndrome (listed in document)
C50.011	Primary diagnosis codes referenced for physical therapy filing
C50.929	Primary diagnosis codes referenced for physical therapy filing

Codes referenced via web toolmixed

No codes listed

inv-09: Minimum hospital stay — 48 hours after mastectomy; 24 hours after axillary node dissection

Minimum hospital stay after mastectomy (Commercial members)Minimum of 48 hours inpatient coverage following mastectomy; early discharge (<48 hours) requires at least one home visit by a physician or registered nurse.

Minimum hospital stay after axillary node dissection (Commercial members)Minimum of 24 hours inpatient coverage following axillary node dissection; early discharge (<24 hours) requires at least one home visit by a physician or registered nurse.

Home visit requirement for early dischargeIf discharged earlier than the mandated minimums, coverage shall include a minimum of one home visit conducted by a physician or registered nurse; home care services are available if the member participates in an early discharge program.

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for Medicare Advantage plans and is recommended for Commercial products for certain covered procedures related to mastectomy, breast reconstruction, and implant removal. Some surgery codes may require medical review to determine if coverage criteria are met.

Medicare Advantage: prior authorization required
Commercial Products: prior authorization recommended for some procedures
Authorization may be procedure-code specific — check the web-based tool

Prior Authorization

Prior Authorization via Web-Based Tool

Use the Prior Authorization via Web-Based Tool for Procedures to determine which specific procedure codes require authorization or medical review. The web tool contains the procedure-specific code lists (including codes for breast implant removal and breast reconstruction) that may trigger prior authorization.

Check the web-based tool for procedure-specific authorization requirements

Background and Rationale

Mastectomy may necessitate additional care including breast reconstruction, provision of prosthetic devices, and treatment for physical complications such as lymphedema. Federal law (the Women’s Health and Cancer Rights Act of 1998) requires coverage for all stages of reconstruction of the breast on which the mastectomy was performed, prostheses, reconstruction of the contralateral breast for symmetry, and treatment of physical complications at all stages of the mastectomy.

Rhode Island law parallels the WHCRA for Commercial products and adds state-specific requirements: in-network mastectomy-related services for eligible Commercial members are covered with the specified cost-sharing provisions (including the mandate that certain in-network services be covered without cost share for plans effective on or after January 1, 2019). The state statute also specifies minimum inpatient stay durations: a minimum of 48 hours after mastectomy and 24 hours after axillary node dissection; if an earlier discharge occurs, at least one home visit by a physician or registered nurse is required as part of an early discharge program.

Providers should note that benefits and eligibility are governed by the member’s subscriber or employer agreement, which supersede this policy; consult the member’s plan documents and the payer’s prior authorization web tool for procedure-specific coding and authorization requirements.

Definitions

inv-19: Definition of 'mastectomy' per RI statute

Definition of 'mastectomy' (RI statute)As used in this section, 'mastectomy' means the removal of all or part of a breast.

Statutory sourceRIGL 27-20-29 (Mastectomy Treatment) — definition appears within the statute's coverage provisions.

Context of useDefinition applies to required coverage for reconstruction, prostheses, symmetry procedures, and related services under Rhode Island law and plan notices.

inv-20: Definition of prosthetic devices — inclusion of initial and subsequent devices per order

Scope of 'prosthetic devices' (RI statute)'Prosthetic devices' means and includes the provision of initial and subsequent prosthetic devices pursuant to an order of the patient's physician, physician assistant, advance practice registered nurse, or surgeon.

Payer practice note