CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Mastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays

Defines coverage, cost-share requirements, and mandated services for mastectomy, breast reconstruction, prostheses, related garments, and post-mastectomy hospital stays for Blue Cross Blue Shield - Rhode Island members (Commercial and BlueCHiP for Medicare distinctions noted).

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2019

Next Review DateN/A

Key ActionObtain prior authorization when required (required for BlueCHiP for Medicare; recommended for some Commercial procedures) and use the payer's web-based tool for code-specific review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

48 hMin hospital stay after mastectomy (Commercial)

24 hMin hospital stay after axillary node dissection (Commercial)

A4280, L8000-L8039Breast prosthesis HCPCS codes

E0676, S8420-S8429Compression garment HCPCS codes

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Covered CPT ranges (mandated services)

Coverage Criteria and Mandates

Mandated reconstruction, prostheses, symmetry, and complication treatment

Covered when mandated services apply under WHCRA and Rhode Island law:

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 per WHCRA and RIGL 27-20-29 in consultation with the attending clinician.

Minimum hospital stay and early discharge home visit requirements

Post-operative hospital stay coverage for in-network Commercial members (state mandate):

Hospital stay minimums: Coverage for a minimum of 48 hours after a mastectomy and a minimum of 24 hours after an axillary node dissection.48 hours mastectomy; 24 hours axillary node dissection

If early discharge (<48 or <24 hours), coverage shall include at least one home visit by a physician or registered nurse; plan cost sharing applies to home care services.

Required reconstruction and prostheses coverage

Covered services required by federal WHCRA and Rhode Island statutes

Statutory coverage requirements: Reconstruction of the breast on which mastectomy was performed; prostheses and treatment of physical complications (including lymphedema) at all stages of mastectomy; reconstruction of the other breast for symmetry; coverage to be provided in a manner determined in consultation with the attending clinician and the patient.

Derived from WHCRA and RIGL 27-20-29

Mastectomy and axillary node dissection hospital-stay coverage

Hospital stay coverage required by Rhode Island statute

Minimum inpatient stay: Coverage for a minimum 48-hour hospital stay after mastectomy and a minimum 24-hour hospital stay after axillary node dissection, unless the attending physician, in consultation with and upon agreement by the patient, decides to shorten the stay; if early discharge occurs, coverage must include at least one home visit by a physician or registered nurse.

RIGL 27-20-29.1

Rhode Island mandates do not apply to BlueCHiP for Medicare. For Commercial in‑network members, the state amendment enacted for plans with effective dates on or after January 1, 2019 requires that mandated mastectomy‑related services (reconstruction, prostheses, symmetry procedures, and treatment of physical complications) be covered with no cost‑share for in‑network services as specified by the statute and federal WHCRA requirements.

The statute explicitly permits health plans and issuers to conduct managed‑care reviews and medical‑necessity reviews of services provided under the mastectomy coverage requirements. The law also states that nothing in the statute prevents a group health plan or carrier from negotiating the level and type of reimbursement with providers for care furnished in accordance with the statute.

Procedure Codes, HCPCS, and Hospital Stay Values

Covered CPT Codes (mandated services)CPTCovered

19301-19307	CPT codes listed in policy for mastectomy/reconstruction
19316-19350	CPT codes listed in policy for mastectomy/reconstruction
19357-19396	CPT codes listed in policy for mastectomy/reconstruction

Breast Prosthesis HCPCS CodesHCPCSCovered

A4280	Breast prosthesis
L8000-L8039	Breast prosthesis series

Compression Garments HCPCS CodesHCPCSCovered

E0676	Compression garment/device
S8420-S8429	Compression garment/device series

Referenced procedure codesmixed

See Prior Authorization policy

Refer to Prior Authorization via Web-Based Tool for Procedures for codes specific to breast implant removal and breast reconstruction review

inv-11: Minimum hospital stay after mastectomy

Minimum hospital stay (mastectomy)>= 48 hours hospital time after mastectomy (Commercial in‑network per RI statute)

Early discharge provisionAttending physician may shorten stay in consultation with and upon agreement by the patient; if discharged early, coverage must include at least one home visit by a physician or registered nurse

Appeal rightSubscriber may appeal a denial of benefits under this section in accordance with Department of Health regulations

inv-12: Minimum hospital stay after axillary node dissection

Minimum hospital stay (axillary node dissection)>= 24 hours hospital time after axillary node dissection (Commercial in‑network per RI statute)

Prior Authorization, Notices, and Appeals

Prior Authorization

Prior Authorization Required

Prior authorization is required for BlueCHiP for Medicare and is recommended for Commercial products for some covered procedures in this policy. Some procedure codes in the surgery section may need medical review to determine if coverage requirements are met and may be denied without appropriate prior authorization or medical documentation.

Prior authorization requirements vary by product (BlueCHiP for Medicare vs Commercial).
Some surgery and reconstruction procedure codes require medical review; see the payer prior-authorization tool for the specific code list.

Note

Prior Authorization via Web-Based Tool

Prior authorization requests and the specific procedure codes subject to review are managed through the payer's web-based tool. Providers should use the Prior Authorization via Web-Based Tool for Procedures policy and the online portal to submit requests and to view the current list of codes that require review.

Refer to the Prior Authorization via Web-Based Tool for Procedures policy for codes specific to breast implant removal and breast reconstruction.

Background and Scope

Mastectomy may be followed by a range of services that are covered under federal and state mandates: reconstructive surgery of the breast on which the mastectomy was performed, provision of prosthetic devices, surgery of the contralateral breast to achieve symmetry, and treatment of physical complications (including lymphedema) at all stages of care. Rhode Island law (RIGL 27‑20‑29 and related provisions) and the federal Women's Health and Cancer Rights Act (WHCRA) require that coverage be provided in a manner determined in consultation with the attending clinician and the patient. Additionally, the statute requires written notice to plan participants and beneficiaries about the availability of these coverages and defines prosthetic devices to include initial and subsequent devices provided pursuant to a treating clinician's order.

Key Definitions

inv-22: Mastectomy definition (state law phrasing)

Statutory definition (mastectomy)"Mastectomy" means the removal of all or part of a breast (RIGL 27‑20‑29).

Scope of coverageRIGL 27‑20‑29 requires coverage for reconstruction of the breast on which the mastectomy was performed and related services, in consultation with the attending clinician and the patient.

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

inv-23: mastectomy — alternate entry (synonym/clarification)

Synonym/clarification'Mastectomy' — means the removal of all or part of a breast (as used in RIGL 27‑20‑29).

ContextTerm is used within the statute to trigger coverage obligations for reconstruction, prostheses, symmetry surgery, and treatment of complications.

Quick Metrics

48hrs — minimum hospital stay after mastectomy (Commercial)

24hrs — minimum hospital stay after axillary node dissection (Commercial)

1home visit required if early discharge

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2019

Next Review DateN/A

Key ActionObtain prior authorization when required (required for BlueCHiP for Medicare; recommended for some Commercial procedures) and use the payer's web-based tool for code-specific review.

SourceLink

On This Page

Home visit requirementMinimum of one home visit conducted by a physician or registered nurse when early discharge occurs

Use the payer web-based prior authorization portal for submission and status checks.

Note

Notice to Members — Availability of Coverage

Written notice of the availability of coverage for reconstruction, prostheses, and treatment of complications following mastectomy must be delivered to participants upon enrollment and annually thereafter. Group health plans and issuers must also include notice regarding mastectomy-related coverage in any yearly informational packet and prominently in plan literature or correspondence.

Notice must state availability of coverage for reconstruction of the operated breast, reconstruction of the contralateral breast for symmetry, and prostheses and treatment of complications at all stages of mastectomy.
Deliver notice at enrollment and annually; include it in yearly informational packets and plan materials.

Note

Notice to Members — Hospital Stay Minimums

Rhode Island law requires coverage of a minimum 48-hour hospital stay after mastectomy (24 hours after axillary node dissection) unless the attending physician and patient agree to an earlier discharge. If an early discharge occurs, coverage must include at least one home visit by a physician or registered nurse. Members have appeal rights if benefits required by this statute are denied.

Minimum 48-hour inpatient coverage after mastectomy (24 hours after axillary node dissection) unless shortened by attending physician with patient agreement.
If early discharge (<48 hrs for mastectomy, <24 hrs for axillary node dissection), coverage must include at least one home visit by a physician or RN.

Denial Risk

Appeal Rights for Denied Hospital-Stay Benefits

Members who are aggrieved by a denial of benefits required under Rhode Island law (including denials of required hospital-stay benefits) may appeal the denial in accordance with applicable Department of Health regulations and the plan's grievance and appeals procedures. Providers should inform members of their right to appeal when a denial of these statutory benefits occurs.

Appeals of denials for mastectomy-related hospital-stay benefits are processed per state regulations and the plan's appeal procedures.
Providers should notify members of appeal rights when such denials occur and assist with submission of required appeal documentation.

ApplicabilityApplies to individual and group health‑insurance coverage and health‑benefit plans delivered, issued for delivery, or renewed in Rhode Island as specified by statute.

inv-24: prosthetic devices definition

Statutory scope"Prosthetic devices" includes provision of initial and subsequent prosthetic devices pursuant to an order of the patient's physician, physician assistant, advance practice registered nurse, or surgeon (RIGL 27‑20‑29).

Coverage requirementRIGL 27‑20‑29 mandates coverage for prostheses and treatment of complications (including lymphedema) at all stages of mastectomy, in consultation with the attending clinician and the patient.

Notice and positioningPlans must provide written notice to enrollees regarding this coverage, prominently positioned in plan literature or informational packets; notice transmitted upon enrollment and annually.