Mastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays
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Defines coverage, cost-share, and mandated services for mastectomy treatment, breast reconstruction, prostheses, lymphedema treatment, related physical therapy and minimum hospital stay/home visit requirements for BCBSRI members; distinguishes applicability for Commercial products vs Medicare Advantage Plans.
No material clinical or coverage changes in this revision.
Coverage, Applicability, and Inpatient Stay Requirements
Mandated Coverage and Inpatient Stay Requirements
Mandated coverage under WHCRA and Rhode Island law for eligible insureds; scope differs by product:
Based on chunks 9,6,8
Based on chunks 5,9,19
Based on chunk 16
Statutorily mandated coverage
Covered when requirements of WHCRA and Rhode Island law are met, in consultation with the attending clinician and the patient.
Derived from WHCRA and RIGL 27‑20‑29
RIGL 27‑20‑29 and RIGL 27‑20‑29.1
Rhode Island statutory mandates described in this policy do not apply to Medicare Advantage Plans. For Medicare Advantage members, covered services and any applicable cost sharing follow Medicare rules and the member's plan terms rather than the state-mandated no-cost-share provisions.
This medical policy is provided for informational purposes and is not a guarantee of payment. Coverage, benefits, and eligibility are determined by the member's subscriber agreement, member certificate, and/or employer agreement, which supersede this policy.
Medical Criteria: Not applicable.
If services are determined to be not medically necessary (or are medically necessary but are non-covered benefits), the provider may not charge the member for those services unless the member has been informed and has provided written agreement in advance to assume financial responsibility.
Relevant Procedure, Therapy, Prosthesis, and Diagnosis Codes; Hospital Stay Durations
| 11920 | Tattooing, areola and/or nipple, including local anesthetic (listed under Surgery section) |
| 11921 | Tattooing, areola and/or nipple, with other specified service |
| 11922 | Tattooing, areola and/or nipple, complex |
| 19301-19307 | Breast reconstruction/breast surgery CPT range listed |
| 19316-19350 | Breast reconstruction/breast surgery CPT range listed |
| 19357-19396 | Breast reconstruction/breast surgery CPT range listed |
| 97010-97016 | Physical therapy modalities |
| 97022 | Whirlpool, not elsewhere classified |
| 97110-97140 | Therapeutic procedures and manual therapy (note: 97140 filed with diagnosis I97.2) |
| 97161-97164 | Physical therapy evaluation codes |
| A4280 | Breast prosthesis (HCPCS) |
| L8000-L8039 | Breast prosthesis supplies (HCPCS range) |
| I97.2 | Post mastectomy lymphedema syndrome (used as primary dx for some PT and garment billing, effective 1/1/2020) |
| C50.011-C50.929 | Malignant neoplasm of breast primary diagnosis code range referenced for PT billing |
| No codes listed |
Prior Authorization, Documentation, Notices, and Medical Review
Obtain prior authorization for listed surgery codes
Prior authorization is required for Medicare Advantage Plans and is recommended for Commercial products for some of the covered surgery codes listed in this policy (see CPT codes 11920, 11921, 11922, 19301-19307, 19316-19350, 19357-19396). Some surgery codes may also need medical review to determine if coverage requirements are met; refer to the Prior Authorization via Web-Based Tool for Procedures policy for the specific procedures that require authorization or review.
- Applies to listed surgery CPT codes in the policy
- Commercial: authorization recommended; Medicare Advantage: authorization required
Use web-based prior authorization tool for reconstruction and implant removal
Certain breast reconstruction and breast implant removal procedures require prior authorization via BCBSRI’s web‑based prior authorization tool. Providers must consult the Prior Authorization via Web‑Based Tool for Procedures policy to identify the specific procedure codes that require submission.
- Use the web‑based prior authorization tool referenced in the related policy
- See Prior Authorization via Web‑Based Tool for Procedures for the list of affected codes
Submit clinical documentation when codes require medical review
Some surgery codes listed in the surgery section may require medical review to determine if coverage requirements are met. If a code is subject to medical review, submit supporting clinical documentation with the prior authorization request per the referenced prior‑auth policy.
- Medical review may be required to confirm coverage criteria
- Attach clinical records when submitting codes that may require review
Bill prostheses and garments per CMS guidelines and file with correct primary diagnosis
Follow CMS dispensing and replacement guidelines for prostheses and compression garments for both Commercial products and Medicare Advantage Plans; bill and file prosthesis and garment claims consistent with those guidelines and with the primary diagnosis codes referenced (e.g., I97.2 for post‑mastectomy lymphedema when applicable).
- Dispensing and replacement limits follow CMS guidelines
- File related PT and garment claims with the referenced primary diagnosis codes (C50.x or I97.2)
When tattoo artist performs nipple/areola tattooing, member must complete special handling form and provide invoice
If nipple/areola tattooing is performed by a tattoo artist (rather than a physician), the member must complete BCBSRI’s special handling form and attach a copy of the tattoo invoice, then mail the completed form and invoice to the address shown on the form; permanent makeup artists must be licensed as tattoo artists in the state where services are rendered.
Provide written notice of reconstruction/prosthetic coverage upon enrollment and annually
Provide written notice to enrollees about the availability of reconstruction and prosthetic coverage at enrollment and annually; plans must also include notice about mandated hospital stay coverage in mass mailings or informational packets to enrollees.
- Written notice of availability of the coverage delivered upon enrollment and annually
- Plans must transmit notice as part of yearly informational packets or in next mass mailing
Expect prior authorization and possible medical‑necessity review for some procedures
Prior authorization is required for Medicare Advantage Plans for some covered procedures and may be recommended for Commercial products; for certain listed procedures the plan may require medical‑necessity review before coverage is determined.
- Medicare Advantage: prior authorization required for some procedures
- Commercial: prior authorization recommended; some codes may still be subject to medical‑necessity review
Do not deny enrollment or penalize providers to avoid WHCRA/Rhode Island requirements; appeals available
Plans and issuers may not deny eligibility, continued eligibility, or penalize providers solely to avoid compliance with WHCRA or Rhode Island mastectomy statutes. Members may appeal denials of benefits under the mastectomy hospital stay statute in accordance with Department of Health regulations.
- Prohibits denying enrollment/renewal or penalizing providers to avoid WHCRA or RIGL requirements
- Subscribers aggrieved by denial of mastectomy hospital stay benefits may appeal per department of health regulations
Legal and Policy Background
Federal and Rhode Island law require coverage for mastectomy-related reconstructive services. Under the Women's Health and Cancer Rights Act (WHCRA) and R.I. Gen. Laws § 27-20-29, coverage must include 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 — at all stages of care.
Rhode Island law additionally mandates minimum inpatient coverage durations for Commercial in-network members: a minimum of 48 hours inpatient stay after mastectomy and a minimum of 24 hours 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.
Key Definitions
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