CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Mastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays Mandates

Governs coverage requirements and cost-sharing mandates for mastectomy treatment, breast reconstruction, prostheses, related services, and minimum post-mastectomy hospital stays for Blue Cross & Blue Shield of Rhode Island members (Commercial) and notes applicability to 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 changes

Effective DateJan 1, 2019

Next Review DateN/A

Key ActionObtain prior authorization via the payer's web-based tool for applicable breast reconstruction and implant removal procedures when required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

48minimum stay after mastectomy (hrs)

24minimum stay after axillary node dissection (hrs)

CPT listsurgery code set

HCPCS & CPTprosthesis/garment codes

Coverage Criteria and Mandates

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Mandated Coverage Criteria

Covered when the following federal and state mandates apply

Mandated services: 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.

Applies under WHCRA and RIGL 27-20-29

Commercial cost-share waiver: For Commercial Products (plans with effective dates on or after Jan 1, 2019), in-network services related to mastectomy treatment as defined by the listed CPT/HCPCS codes are covered with no cost share.

RI amendment effective Jan 1, 2019

Plan notice requirement: Plans must provide written notice to participants and beneficiaries upon enrollment and annually regarding the coverage required under WHCRA and Rhode Island law; notice must be prominently positioned in plan literature or annual packets.

Per WHCRA and RIGL 27-20-29

Statutorily required services

Covered when following statutory conditions are met

WHCRA and RI statutory coverage: Plans that provide mastectomy benefits must also cover reconstruction of the breast on which mastectomy was performed; reconstruction of the other breast for symmetry; prostheses; and treatment of physical complications including lymphedema.

Coverage provided in a manner determined in consultation with the attending physician; may be subject to usual plan deductibles/coinsurance unless waived by state amendment for Commercial plans.

Mastectomy hospital stay coverage

Covered hospital stay durations

Minimum inpatient stay: Minimum 48-hour inpatient coverage after mastectomy OR minimum 24-hour inpatient coverage after axillary node dissection.48 hours; 24 hours

Any decision to shorten must 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; home care services are available but plan cost sharing may apply unless the service is separately mandated.

Rhode Island mandates do not apply to Medicare Advantage Plans. Medicare Advantage plans follow their own applicable coverage and cost‑share rules; the state statutory requirements described for Commercial Products are not binding on Medicare Advantage products.

The statute does not preclude standard managed‑care or medical‑necessity reviews by insurers. Coverage required under the Rhode Island mastectomy statute must still be provided "in a manner determined in consultation with the attending physician," and nothing in the law prevents a plan from conducting usual utilization review or negotiating reimbursement arrangements with providers.

Medical criteria: Not applicable — this policy section does not specify separate medical‑necessity criteria beyond the statutory coverage mandates described elsewhere in the document.

Billing and Code References

Minimum hospital stay after mastectomy — 48 hours

Minimum inpatient coverage after mastectomy48 hours

ApplicabilityApplies to individual or group hospital or medical services plans delivered, issued for, or renewed in Rhode Island

Shortened stay exceptionMay be shortened only by attending physician in consultation with and upon agreement by the patient

Appeal rightsSubscribers may appeal denials of benefits under this section per Department of Health regulations

Minimum hospital stay after axillary node dissection — 24 hours

Minimum inpatient coverage after axillary node dissection24 hours

ApplicabilityApplies to individual or group hospital or medical services plans delivered, issued for, or renewed in Rhode Island

Shortened stay exceptionMay be shortened only by attending physician in consultation with and upon agreement by the patient

Early discharge careIf patient participates in early discharge program, specified home care provisions may apply (per statute)

Provider Requirements and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products for some covered procedures. Some surgery CPT codes listed in the policy may require medical review to determine if coverage criteria are met.

Prior authorization required for Medicare Advantage Plans; recommended for Commercial Products
See Prior Authorization via Web-Based Tool for Procedures for the specific list of procedure codes subject to review

Prior Authorization

Prior authorization via web tool

Prior authorization requirements for breast implant removal and breast reconstruction are handled via Blue Cross & Blue Shield of Rhode Island's web-based Prior Authorization tool. Providers must check the web tool for the current list of CPT codes that require review and follow the submission instructions there.

Use the Prior Authorization via Web-Based Tool for Procedures to determine which breast implant removal and breast reconstruction codes require review
Follow the web tool submission process for documentation and routing

Documentation Required

Tattooing documentation and special handling

If nipple/areola tattooing (CPT 11920, 11921, 11922) is performed by a tattoo artist rather than a physician, the tattoo artist must be licensed as a tattoo artist in the state where services are rendered. Members who choose a licensed tattoo artist must complete the payer’s handling form, attach a copy of the tattoo service invoice, and mail the completed form to the address on the form. For assistance, members should contact BCBSRI Customer Service.

Tattooing covered when performed by a physician or a licensed tattoo artist (CPT 11920, 11921, 11922)
Permanent makeup artists must be licensed as tattoo artists in the state where services are rendered
Members must complete the handling form, include the tattoo invoice, and mail it per instructions; contact BCBSRI Customer Service for help

Note

Required member notice

Plans must provide written notice to participants/beneficiaries upon enrollment and annually regarding WHCRA and state-required mastectomy coverage, including reconstruction, prostheses, and mandated hospital-stay benefits.

WHCRA requires coverage for reconstructive surgery and related benefits in consultation with the attending physician
Rhode Island law (RIGL 27-20-29 and 27-20-29.1) requires written notice to enrollees upon enrollment and annually
Members have appeal rights for denials of mandated mastectomy hospital-stay benefits per state regulations

Policy Background and Scope

This policy implements the federal Women’s Health and Cancer Rights Act (WHCRA) and Rhode Island statutes (RIGL 27‑20‑29 and related provisions) that require coverage for reconstruction following mastectomy, provision of prosthetic devices, reconstruction of the contralateral breast for symmetry, and treatment of physical complications of mastectomy including lymphedema. For Commercial Products (effective on or after January 1, 2019) the state amendment requires in‑network services related to mastectomy treatment be provided with no cost share as specified by the listed CPT/HCPCS codes. The statute also mandates minimum inpatient coverage durations—48 hours after mastectomy and 24 hours after axillary node dissection—with early discharge options requiring clinician and patient agreement and provision for at least one home visit when appropriate. Plans must provide written notice of these coverage rights to participants upon enrollment and annually.

Key Definitions

WHCRA-covered services

Scope of WHCRA-covered servicesAll stages of reconstruction of the breast on which the mastectomy was performed

ProsthesesCoverage includes provision of prosthetic devices

Contralateral breast proceduresSurgery and reconstruction of the other breast to produce a symmetrical appearance

Treatment of complicationsTreatment of physical complications at all stages of the mastectomy, including lymphedema

mastectomy

DefinitionThe removal of all or part of a breast

ContextDefinition as used in RIGL 27-20-29 (Rhode Island statute) governing mastectomy-related coverage

Related notice requirementWritten notice of availability of such coverage must be delivered to participant upon enrollment and annually thereafter

prosthetic devices

DefinitionIncludes provision of initial and subsequent prosthetic devices pursuant to an order of the patient’s physician

Statutory sourceDefinition appears in RIGL 27-20-29 regarding mastectomy treatment and prosthetic device coverage

Ordering requirementProsthetic devices are provided pursuant to a clinician’s order (physician, physician assistant, or advanced practice clinician as applicable)

Document History

2019-01-01policy_effective

Policy effective date for Commercial Products coverage changes (state amendment effective Jan 1, 2019) implementing RI mastectomy treatment mandates and cost-share provisions.

1998-10-21federal_law_effective

Women’s Health and Cancer Rights Act (WHCRA) signed into law; requires coverage for reconstructive surgery, prostheses, and related mastectomy benefits for group health plans effective for plan years starting on or after this date.

2005-01-01state_statute_effective

Rhode Island General Law (RIGL 27-20-29) mastectomy treatment coverage effective for policies delivered, issued for delivery, or renewed in the state on or after January 1, 2005, requiring reconstruction, prostheses, and related services.

statutory_history_noticeLatest

RIGL 27-20-29.1 establishes minimum hospital stay requirements: 48 hours after mastectomy and 24 hours after axillary node dissection; decisions to shorten require attending physician and patient agreement.