Mastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays
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Defines coverage requirements and mandates for mastectomy services, reconstruction, prostheses, lymphedema treatment, and minimum hospital stays under WHCRA and Rhode Island law for BCBSRI members; distinguishes Commercial product obligations from BlueCHiP for Medicare.
No material clinical or coverage changes in this revision.
Coverage Criteria and Mandates
WHCRA and RIGL mandated coverage
Covered when services fall within the federal WHCRA and Rhode Island mandates:
Coverage to be determined in consultation with the attending physician, physician assistant, or advance practice registered nurse and the patient per WHCRA and RIGL.
Minimum inpatient hospital coverage (Commercial products)
Commercial (in-network) coverage requirements for post-operative inpatient stay:
Any decision to shorten these minimums shall be made by the attending physician in consultation with and upon agreement by the patient. If early discharge occurs, coverage shall include at least one home visit by a physician or registered nurse; applicable cost sharing applies for home care unless the service is otherwise mandated to be no cost share.
Statutory coverage requirements
Covered when statutory conditions are met
Coverage determined in consultation with the attending clinician and the patient; WHCRA applies to group health plans and may be subject to plan deductibles and coinsurance consistent with other benefits.
Applies to all individual or group hospital or medical services plan contracts delivered, issued for delivery, or renewed in Rhode Island; subscribers may appeal denials under department of health regulations.
The Rhode Island statutory mandates described in this policy do not apply to BlueCHiP for Medicare plans. BlueCHiP for Medicare is explicitly excluded from the state mastectomy/reconstruction requirements referenced in this document.
This document does not state any additional exclusions beyond statutory applicability. Plans retain the ability to negotiate provider reimbursement and to perform managed-care or medical-necessity determinations consistent with other benefit provisions; the Rhode Island statute focuses on minimum hospital-stay coverage and member notice rather than prescribing reimbursement levels.
Codes, Hospital Stay Minimums, and Related Coding Guidance
| 19301-19307, 19316-19350; 19357-19396 | Surgery CPT code ranges defined as mastectomy-related in policy |
| 97140 | Physical therapy (filed with ICD-10 I97.2 for post mastectomy lymphedema syndrome) |
| A4280 | Breast prosthesis |
| L8000-L8039 | Breast prosthesis HCPCS codes |
| E0676 | Compression garment/device |
| S8420-S8429 | Compression garments HCPCS codes (filed with ICD-10 I97.2) |
| No codes listed |
| No codes listed |
Prior Authorization, Notification, and Provider Responsibilities
Prior authorization required for listed mastectomy surgery codes
Prior authorization is required for BlueCHiP for Medicare and is recommended for Commercial products for some of the covered mastectomy-related surgery codes (CPT ranges 19301-19307, 19316-19350, 19357-19396). Some codes in the surgery section may require medical review to determine if coverage requirements are met; refer to the Prior Authorization via Web-Based Tool for Procedures policy for specific procedure code listings and review process.
- Prior authorization required for BlueCHiP for Medicare; recommended for Commercial products.
- Surgery CPT code ranges defined as mastectomy-related: 19301-19307, 19316-19350, 19357-19396.
- Some surgery codes may need medical review to confirm coverage; see related Prior Authorization via Web-Based Tool for Procedures policy.
Use web-based prior authorization for implant removal and reconstruction
Certain breast procedures — including breast implant removal and breast reconstruction — require prior authorization via Blue Cross Blue Shield's Prior Authorization via Web-Based Tool for Procedures; see that related policy for the specific codes and web-based submission process.
- Submit prior authorization requests using the payer's web-based tool as directed in the related policy.
- Consult the Prior Authorization via Web-Based Tool for Procedures policy for the exact CPT/HCPCS codes subject to review.
Obtain prior authorization where required
Prior authorization is required for BlueCHiP for Medicare and recommended for Commercial products for some covered procedures; where required, submit prior authorization requests before performing the service.
- Obtain prior authorization for BlueCHiP for Medicare members for applicable procedures.
- For Commercial members, follow payer guidance—prior authorization is recommended and some codes may be subject to review.
Submit clinical documentation for prior auth medical review
Refer prior authorization and medical necessity questions to the Prior Authorization via Web-Based Tool for Procedures policy and submit necessary clinical documentation when requested for medical review.
- Use the web-based tool referenced in the related policy for submission.
- Provide clinical documentation to support medical necessity when medical review is requested.
Provide required written member notice of mastectomy coverage
Ensure written notice of the availability of mastectomy-related coverage is delivered to participants upon enrollment and annually thereafter as required by RIGL 27-20-29; include the notice prominently in plan literature and as part of yearly informational packets.
- Deliver written notice upon enrollment and annually.
- Prominently position the notice in any literature or correspondence and transmit it as part of yearly informational packets.
Include mastectomy hospital-stay notice in mass mailings/informational packets
Plans must provide notice to enrollees in the next mass mailing or as part of any informational packet sent to the enrollee regarding the coverage required by RIGL 27-20-29.1 (mastectomy hospital stay).
- Include mastectomy hospital stay coverage notice in the next mass mailing to employees or in any informational packet to enrollees.
Be prepared for medical review on some procedure codes
Some mastectomy-related surgery codes may require medical review to determine whether coverage criteria are met; for BlueCHiP for Medicare prior authorization is required and Commercial requests may be subject to review.
- Expect medical review for certain procedure codes listed in the surgery section.
- Refer to the Prior Authorization via Web-Based Tool for Procedures policy for which codes are reviewed.
Member appeal rights for denied mastectomy hospital-stay benefits
Any subscriber aggrieved by a denial of benefits under the mastectomy hospital stay provision may appeal the denial in accordance with the Department of Health regulations; plans may not terminate services or penalize providers who order care consistent with the statute.
- Subscribers may appeal denials per Department of Health regulations promulgated under chapter 23 of title 17.
- Plans cannot terminate services, reduce capitation payment, or penalize attending providers for care consistent with RIGL 27-20-29.1.
Policy Background and Legal Basis
Federal and Rhode Island law require coverage for reconstruction and related services following mastectomy. Under the Women's Health and Cancer Rights Act (WHCRA) and Rhode Island statute, covered services include all stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the contralateral breast for symmetry, provision of prosthetic devices, and treatment of physical complications of mastectomy, including lymphedema. Coverage decisions are to be made in consultation with the attending clinician and the patient.
Rhode Island statute also mandates minimum inpatient hospital coverage for procedures related to mastectomy: a minimum of forty-eight (48) hours in the hospital after a mastectomy and a minimum of twenty-four (24) hours after an axillary node dissection unless the attending physician, with the patient's agreement, shortens the stay. If an early discharge occurs (shorter than these minimums), coverage must include at least one home visit by a physician or registered nurse.
The statute further requires plans subject to the law to provide notice to enrollees regarding the availability of mastectomy-related coverage in the plan’s next mass mailing or informational packet, and provides an appeals process for subscribers aggrieved by denials under the hospital-stay provision.
Key Definitions Used in This Policy
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