CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Mastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays

Defines coverage requirements and mandated services under WHCRA and Rhode Island statutes for mastectomy-related reconstruction, prostheses, treatment of complications (including lymphedema), nipple/areola tattooing, related physical therapy, prostheses, compression garments, and minimum inpatient hospital stays/early discharge home visit requirements. Distinguishes applicability for Commercial products (subject to RI mandates) and BlueCHiP for Medicare (RI mandates do not apply).

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Mastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2001

Next Review Date

Key ActionFollow prior authorization requirements: prior authorization is required for BlueCHiP for Medicare and recommended for some Commercial procedures; refer to the Prior Authorization via Web-Based Tool for Procedures policy and use the Special Handling Form when nipple/areola tattooing is performed by a licensed tattoo artist.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

≥48hRequired mastectomy inpatient stay (Commercial)

≥24hRequired axillary node dissection inpatient stay (Commercial)

MandatedWHCRA mandated reconstruction/prosthesis coverage

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Coverage Summary

This policy (effective 2001-01-01, status: CURRENT) defines coverage requirements under the federal Women's Health and Cancer Rights Act (WHCRA) and Rhode Island statutes for mastectomy-related care. It mandates coverage for breast reconstruction of the mastectomy side, prostheses (initial and subsequent), surgery and reconstruction of the contralateral breast for symmetry, treatment of physical complications including lymphedema, nipple/areola tattooing, related physical therapy, specified compression garments/devices, and HCPCS-listed prosthetic components. Rhode Island law requires minimum inpatient stays for Commercial products (≥48 hours after mastectomy, ≥24 hours after axillary node dissection) with provisions for early discharge home visits. For Commercial plans with effective dates on or after 2019-01-01, in-network services defined by the listed CPT/HCPCS codes are covered with no in-network cost share (HSA-qualified HDHPs: cost sharing applies after the deductible). Rhode Island mandates do not apply to BlueCHiP for Medicare; those Medicare products are covered subject to applicable CMS-aligned cost share and dispensing/replacement rules.

Mastectomy and axillary node dissection inpatient stay thresholds and document dates

Mastectomy minimum inpatient stay (Commercial)>= 48 hours

Axillary node dissection minimum inpatient stay (Commercial)>= 24 hours

Effective date2001-01-01

Policy last review2020-01-07

StatusCURRENT

Mandated Coverage Criteria

Codes

WHCRA / Surgery CPT codes (defines services that must be covered)CPTCovered

11920	Nipple/areola tattooing
11921	Nipple/areola tattooing
11922	Nipple/areola tattooing
19301	Mastectomy/reconstruction related surgery range
19302	Mastectomy/reconstruction related surgery range
19303	Mastectomy/reconstruction related surgery range
19304	Mastectomy/reconstruction related surgery range
19305	Mastectomy/reconstruction related surgery range
19306	Mastectomy/reconstruction related surgery range
19307	Mastectomy/reconstruction related surgery range

1–10 of 56

1/6

Physical therapy CPT (post-mastectomy lymphedema filing)CPTCovered

97140

Manual therapy techniques (filed with ICD-10 diagnosis code I97.2 for Post mastectomy lymphedema syndrome)

Breast prosthesis HCPCSHCPCSCovered

A4280	Breast prosthesis component
L8000	Prosthetic device code (listed as L8OOO in doc)
L8039	Breast prosthesis code

Compression garments and devices HCPCSHCPCSCovered

E0676	Compression garment/device
S8420	Post-mastectomy compression device/garment
S8429	Post-mastectomy compression device/garment
A4465	Compression garment
L0970	Compression garment (effective 2020-01-01)

Provider Actions and Billing Rules

Prior Authorization

Prior authorization for certain procedures

Prior authorization is required for BlueCHiP for Medicare and is recommended for Commercial products for some covered procedures. Some surgery codes may require medical review to determine if coverage requirements are met. See the Prior Authorization via Web-Based Tool for Procedures policy for the specific procedure codes that are reviewed.

Documentation Required

Special handling form for tattoo by tattoo artist

If nipple/areola tattooing (CPT 11920, 11921, 11922) is performed by a licensed tattoo artist, the member must complete the Special Handling Form, attach a copy of the invoice for the tattoo services, and mail the completed form to the address on the form. Permanent makeup artists must be licensed as a tattoo artist in the state where the services are rendered.

Affected codes: 11920, 11921, 11922
Steps: Member completes Special Handling Form, attaches invoice, and mails completed form as instructed

Background and Definitions

This policy documents coverage for mastectomy-related reconstructive surgery and related services pursuant to the federal WHCRA and Rhode Island General Laws (RIGL 27-20-29 and 27-20-29.1). It specifies that WHCRA requires coverage for reconstruction of the breast on which mastectomy was performed, prostheses, reconstruction of the other breast for symmetry, and treatment of complications including lymphedema. Under Rhode Island law, Commercial products must cover these services and, for plans effective on or after 2019-01-01, in-network services defined by the listed CPT/HCPCS codes are provided with no in-network cost share (with HSA-qualified high deductible plans applying cost share after the deductible is met). Rhode Island mandates explicitly do not apply to BlueCHiP for Medicare, and Medicare-product coverage and cost-share follow CMS guidelines for prosthesis and garment dispensing/replacement.

Definitions

Revision History

2001-01-01Effective date

Effective date

2020-01-07ReviewLatest

Last review