Mastectomy Treatment, Breast Reconstruction and Mastectomy Hospital Stays
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Defines coverage requirements and cost-sharing rules for mastectomy, breast reconstruction, prostheses, lymphedema treatment, and mandated post-mastectomy hospital stays for Blue Cross Blue Shield - Rhode Island members (Commercial and BlueCHiP for Medicare distinctions noted).
No material clinical or coverage changes in this revision.
Coverage Criteria and Mandates
WHCRA and RIGL mandated services
Covered per WHCRA and R.I. Gen. Law §27-20-29 when provided in consultation with the attending clinician and patient:
Applies to plans that provide mastectomy benefits; written notice of availability must be delivered at enrollment and annually.
Commercial no cost share mandate
Cost-sharing rule for Commercial in-network services (effective for plans with effective dates on or after 1/1/2019):
Applies to plans with effective dates on or after 1/1/2019; note that HSA-qualified HDHP plans are subject to cost sharing after the deductible is satisfied; the listed CPT and HCPCS codes define the services that may not have cost sharing when rendered by network providers.
Mastectomy hospital stay mandate
Minimum hospital stay and early discharge provisions for Commercial in-network members:
Home care services are available for early discharge but applicable plan cost sharing applies; for services mandated under R.I. Gen. Laws §27-20-29, cost share will not be applied.
Statutory Required Reconstruction and Related Services
Covered when mandated by federal WHCRA and Rhode Island statute for plans that provide mastectomy benefits:
WHCRA permits application of annual deductibles and coinsurance consistent with other benefits, while Rhode Island law requires written notice at enrollment and annually.
Mastectomy and Axillary Node Dissection Hospital Stay Coverage
Covered when ALL of the following are met:
Applies to in-network Commercial plans delivered/issued/renewed in RI; managed-care and medical-necessity reviews may still be conducted per statute.
The Rhode Island statutory mandates described in this policy do not apply to BlueCHiP for Medicare. BlueCHiP for Medicare members are therefore not subject to the state-specific no-cost-share and minimum hospital-stay provisions that apply to Commercial in‑network plans under R.I. law.
Under the federal Women's Health and Cancer Rights Act (WHCRA), mastectomy-related benefits "may be subject to annual deductibles and coinsurance consistent with those established for other benefits under the plan or coverage." Apply deductibles and coinsurance for mastectomy-related services in the same manner as other plan benefits where permitted by the plan and applicable law.
Medical Criteria: Not applicable. This policy does not list separate medical-necessity criteria in this section.
Not specified in this section: the statute permits insurers, hospitals, medical-service corporations and HMOs to conduct managed-care reviews and medical‑necessity reviews as appropriate. Plans may perform such reviews consistent with applicable law and their benefit administration processes.
Billing Codes and Key Coding Rules
| 11920 | Nipple/areola reconstruction; local flap |
| 11921 | Nipple/areola tattooing |
| 11922 | Nipple reconstruction, other |
| 19301 | Mastectomy, partial (e.g., lumpectomy) |
| 19302 | Mastectomy, partial (re-excision) |
| 19303 | Mastectomy, partial with axillary sampling |
| 19304 | Mastectomy, subcutaneous |
| 19305 | Mastectomy, total (simple) |
| 19306 | Mastectomy, modified radical |
| 19307 | Mastectomy, radical |
| 97010 | Physical therapy modalities; hot/cold packs |
| 97011 | Physical therapy modalities; therapeutic procedure |
| 97012 | Physical therapy modalities; mechanical traction |
| 97013 | Physical therapy modalities; other |
| 97014 | Physical therapy modalities; unattended |
| 97015 | Physical therapy modalities; unlisted |
| 97016 | Physical therapy modalities; paraffin bath |
| 97022 | Whirlpool therapy |
| 97110 | Therapeutic exercise |
| 97112 | Neuromuscular re-education |
| A4280 | Breast prosthesis, mastectomy form, silicone or equal |
| L8000 | Breast prosthesis, mastectomy, external, without form |
| L8001 | Breast prosthesis, mastectomy, external, with form |
| L8002 | Breast prosthesis, mastectomy, custom fit |
| L8003 | Breast prosthesis, mastectomy, other |
| L8004 | Breast form, pocketed bra insert |
| L8005 | Breast prosthesis component |
| L8006 | Breast prosthesis, other |
| L8007 | Breast prosthesis, other series |
| L8008 | Breast prosthesis |
| E0676 | Compression pump, non-physician ordered |
| S8420 | Postoperative compression garment, mastectomy |
| S8421 | Postoperative compression garment, mastectomy, other |
| S8422 | Postoperative compression garment, mastectomy, other |
| S8423 | Postoperative compression garment, mastectomy, other |
| S8429 | Postoperative compression garment, mastectomy, unspecified |
| A4465 | Breast support garment |
| L0970 | Breast prosthesis garment, mastectomy bra |
| C50.011 | Malignant neoplasm of nipple and areola, right female breast |
| C50.929 | Malignant neoplasm of breast, unspecified site, female |
| I97.2 | Postmastectomy lymphedema syndrome |
| No codes listed |
Provider Requirements, Prior Authorization, and Member Notices
Prior Authorization and Medical Review
Prior authorization is required for BlueCHiP for Medicare and is recommended for Commercial products for some of the procedures covered by this policy. Some surgery codes may require medical review to determine coverage. Refer to the "Prior Authorization via Web-Based Tool for Procedures" policy for the listing of procedure codes that are reviewed.
- Prior authorization required for BlueCHiP for Medicare; recommended for Commercial for listed surgery CPT codes (see Related Policies).
- Some surgery codes may require medical review to determine if coverage requirements are met.
- See Prior Authorization via Web-Based Tool for Procedures for codes that require review.
Prior Authorization via Web-Based Tool
Certain breast implant removal and breast reconstruction procedures require prior authorization via the payer's web-based tool. Providers should consult the Prior Authorization via Web-Based Tool for Procedures policy for the specific codes and submission instructions.
- Use the web-based prior authorization tool for codes identified in the Prior Authorization via Web-Based Tool for Procedures policy.
- Authorization may be required only if a surgery code is listed in that medical policy.
Special Handling for Nipple/Areola Tattoo Services
Members who elect nipple/areola tattooing as part of breast reconstruction may have the service performed by a physician or by a licensed tattoo artist (permanent makeup artists must be licensed as tattoo artists in the state where services are rendered). When a licensed tattoo artist is used, the member must complete a special handling form and attach a copy of the tattoo service invoice; the completed form and invoice must be mailed to the address on the form. Members needing assistance should contact BCBSRI Customer Service.
- Nipple/areola tattooing is covered when performed by a physician or a licensed tattoo artist (CPT 11920, 11921, 11922).
- If performed by a tattoo artist, member must complete the special handling form and include the tattoo invoice.
- Permanent makeup artists must be licensed as tattoo artists in the state where services are rendered.
Member Notice, Denial and Appeal Protections
Plans must provide written notice of the availability of mastectomy-related coverage upon enrollment and annually thereafter. Insurers may conduct managed-care and medical-necessity reviews, but they may not deny eligibility, enrollment, or renewal solely to avoid mastectomy-related coverage requirements, nor penalize or reduce reimbursement to providers or offer incentives to induce care inconsistent with the statute.
- Written notice of availability of reconstruction and related coverage must be delivered to participants upon enrollment and annually thereafter.
- Insurers may perform medical-necessity and managed-care reviews.
- Carriers may not deny eligibility/enrollment or renewals solely to avoid compliance with the mastectomy treatment statute.
- Carriers may not penalize, reduce reimbursement, or provide incentives to providers to induce noncompliance with the statute.
Policy Background and Authorities
This policy implements federal and state mandates requiring coverage related to mastectomy. Under the federal Women's Health and Cancer Rights Act (WHCRA) and R.I. Gen. Laws §27-20-29, plans that provide mastectomy benefits must cover: reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the opposite breast for symmetry; provision of prostheses; and treatment of physical complications of mastectomy (including lymphedema). Coverage decisions are to be made in consultation with the attending clinician and the patient, and plans must notify participants of these coverage rights upon enrollment and annually.
Definitions
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