CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Mastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays

Defines coverage requirements and state/federal mandates for mastectomy services, breast reconstruction, prostheses, related treatments, and mandated hospital stay durations for Blue Cross Blue Shield Rhode Island members (Commercial and BlueCHiP for Medicare addressed separately).

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays

Policy CodePolicy N/A

Change TypeNo material change

Effective Date01|01

Next Review DateN/A

Key ActionObtain prior authorization via the payer's web-based tool for breast implant removal and breast reconstruction; prior authorization is required for BlueCHiP for Medicare and recommended for Commercial products for some procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

48hMin stay after mastectomy (Commercial)

24hMin stay after axillary node dissection (Commercial)

19301-19396Mandated surgery CPT range

A4280; L8000-L8039Breast prosthesis HCPCS

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Mandated Coverage Criteria

Covered when the following mandated items apply:

Mandated coverage items: 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; and treatment of physical complications at all stages of the mastectomy, including lymphedema.

Per WHCRA and RIGL 27-20-29

In-network cost share for Commercial plans effective on/after 2019-01-01: In-network services related to mastectomy treatment (as defined by the applicable CPT codes) are covered at no cost share for Commercial members with plan effective dates on or after January 1, 2019.

Rhode Island amendment to mirror WHCRA with no in-network cost share for Commercial plans

Minimum hospital stay and early discharge provisions: Coverage must include a minimum of 48 hours in hospital after mastectomy and a minimum of 24 hours after axillary node dissection. If early discharge occurs (in‑patient care less than these minimums), coverage must include at least one home visit by a physician or registered nurse; home care services are available but the plan's applicable cost sharing applies except where RIGL 27-20-29 mandates no cost share.48 hours; 24 hours

Applies to Commercial products; RI mandates do not apply to BlueCHiP for Medicare

Mandated coverage items

Covered when required by WHCRA and Rhode Island statutes:

Statutory coverage mandates: Reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; provision of prostheses; and treatment of physical complications, including lymphedema, at all stages of mastectomy, in a manner determined in consultation with the attending clinician and patient.

Cites WHCRA and RIGL 27-20-29

Minimum hospital stay: Coverage for a minimum 48-hour hospital stay after mastectomy and a minimum 24-hour stay after axillary node dissection, unless the attending physician and patient agree to an earlier discharge. If early discharge occurs, coverage must include at least one home visit by a physician or registered nurse.48 hours; 24 hours

RIGL 27-20-29.1

Rhode Island statutory mandates described in this policy do not apply to BlueCHiP for Medicare plans. For Commercial members, Rhode Island law effective on or after January 1, 2019 requires that in-network services related to mastectomy treatment be provided with no in‑network cost share; that state-level no-cost-share requirement does not extend to BlueCHiP for Medicare.

The Rhode Island statute explicitly states that nothing in the law shall preclude the conducting of managed‑care reviews and medical‑necessity reviews by insurers or managed‑care organizations. While the statute protects member eligibility and prohibits actions to avoid mandated coverage, it does not prohibit insurers from performing utilization review or medical necessity determinations.

Medical criteria are stated as Not applicable for this mandated coverage policy. Coverage obligations arise from federal WHCRA and Rhode Island statute requirements rather than from insurer clinical‑necessity criteria documented in this policy.

This document is provided for informational purposes only and is not a guarantee of payment. Benefits and coverage are determined by the member’s subscriber agreement, evidence of coverage, or employer agreement and those documents take precedence. Services determined to be not medically necessary or otherwise non‑covered under a member’s benefit plan may be denied and are subject to the applicable member benefit documents and appeal processes.

Codes, Hospital Stay, and Billing Notes

Mandated Surgery CPT CodesCPTCovered

19301-19307, 19316-19350, 19357-19396

CPT codes defining mastectomy-related services covered under the mandate (as listed)

Physical TherapyCPTCovered

97140

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

Breast Prosthesis HCPCS CodesHCPCSCovered

A4280, L8000-L8039

Breast prosthesis HCPCS codes

Compression Garments and DevicesHCPCSCovered

E0676, S8420-S8429, L0970

Compression garments and devices HCPCS codes (effective 1/1/2020); filed with ICD-10 I97.2 for Post mastectomy lymphedema syndrome

Codes requiring prior authorizationmixed

see web-based tool

Codes specific to Breast Implant Removal and Breast Reconstruction are referenced via the Prior Authorization via Web-Based Tool for Procedures policy.

Minimum hospital stay

Minimum stay after mastectomy>= 48 hours (coverage for a minimum forty-eight (48) hour time in hospital following mastectomy)

Minimum stay after axillary node dissection>= 24 hours (coverage for a minimum twenty-four (24) hour time in hospital following axillary node dissection)

Shortened stay conditionDecision to shorten made by the attending physician in consultation with and upon agreement by the patient

If early discharge occursCoverage must include a minimum of one home visit conducted by a physician or registered nurse

Provider Responsibilities and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for BlueCHiP for Medicare and is recommended for some Commercial procedures. Some surgical codes may need medical review to determine if coverage requirements are met. Providers must submit prior authorization requests and supporting documentation via the payer's web-based Prior Authorization tool.

Prior authorization required for BlueCHiP for Medicare; recommended for some Commercial procedures.
Some surgical codes may require medical review to determine coverage.
Submit prior authorization requests via the payer web-based tool.

Prior Authorization

Prior Authorization via Web-Based Tool for Breast Implant Removal/Reconstruction

Breast implant removal and breast reconstruction require prior authorization through the payer's web-based Prior Authorization tool. Use the Prior Authorization via Web-Based Tool for Procedures policy to identify the specific procedure codes that must be submitted. Ensure the request includes relevant clinical documentation to support medical necessity.

Breast implant removal and reconstruction require prior authorization via web tool.
See Prior Authorization via Web-Based Tool for Procedures for required codes and submission instructions.
Include clinical documentation to support medical necessity with the submission.

Documentation Required

Benefit Documentation

Refer to the member's applicable Benefit Booklet, Evidence of Coverage (EOC), or Subscriber Agreement for detailed benefit, coverage limits, and cost-share information related to mastectomy, inpatient services, surgery, medical equipment, supplies, and prosthetic devices.

Benefit Booklet / EOC / Subscriber Agreement determines member-specific coverage and limits.
Verify inpatient, surgery, prosthetic device, and supply benefits in the appropriate document before proceeding.

Denial Risk

Non-Discrimination and Eligibility (RIGL 27-20-29)

Per Rhode Island law (RIGL 27-20-29), plans may not deny eligibility or take actions to avoid mastectomy and related prosthetic coverage requirements; insurers may perform managed-care or medical-necessity reviews but may not use eligibility actions to circumvent statutory obligations. Providers should be aware that reimbursement negotiations and utilization reviews are permitted, but coverage protections remain in force.

Plans may not deny eligibility or take actions to avoid WHCRA/RI mastectomy coverage requirements.
Insurers may perform managed-care and medical-necessity reviews, but cannot circumvent statutory coverage mandates.

Denial Risk

Prior Authorization / Medical Review Risk

Some surgical codes associated with implant removal or reconstruction may be subject to medical review to establish coverage. When in doubt, submit a prior authorization request via the web tool so the payer can determine whether coverage criteria are met.

Certain surgery codes may require medical review before coverage is determined.
Submitting prior authorization reduces risk of retrospective denial.

OpenPayer

Mastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays

Coverage Criteria and Mandates

Codes, Hospital Stay, and Billing Notes

Provider Responsibilities and Prior Authorization

Background and Legal Basis

Definitions