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CurrentCurativePolicy CHP-IP-F106

Autologous Breast Reconstruction with Abdominal Flaps (DIEP, SIEA, Free TRAM, and Pedicled TRAM)

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This policy governs medical necessity, inpatient level of care, continued-stay review, discharge readiness, documentation, and coding for immediate or delayed autologous breast reconstruction using DIEP, SIEA, free TRAM, or pedicled TRAM flaps in adults. Implant-based reconstruction, fat grafting, nipple reconstruction, and other procedures performed in outpatient settings are outside this policy.

Policy Summary

PayerCurative

PolicyAutologous Breast Reconstruction with Abdominal Flaps

Policy CodePolicy CHP-IP-F106

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit documentation showing that all procedure-indication criteria and at least one inpatient-setting criterion are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2–4 daysTypical uncomplicated inpatient length of stay

24–72 hoursIntensive flap monitoring

24–48 hoursConcurrent review interval

7–14 daysSurgeon follow-up after discharge

10Discharge-readiness criteria

Medical Necessity and Level-of-Care Criteria

Initial inpatient admission

Inpatient admission is medically necessary when ALL of the following are met.

Procedure indications and inpatient setting

Procedure indications
- Covered reconstructive indication: Reconstruction is related to a mastectomy, immediate or delayed, for cancer, risk reduction, or another reason; is a symmetry procedure on the contralateral breast; or is revision to autologous tissue for implant failure, capsular contracture, infection, or radiation injury.
- Shared decision-making: The reconstructive method was chosen through shared decision-making between the patient and attending surgeon, with risks, alternatives including implant reconstruction, and donor-site effects documented.
- Abdominal donor suitability:

Policy Summary

PayerCurative

PolicyAutologous Breast Reconstruction with Abdominal Flaps

Policy CodePolicy CHP-IP-F106

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit documentation showing that all procedure-indication criteria and at least one inpatient-setting criterion are met.

SourceLink

On This Page

Adequate abdominal donor tissue is present and no prior abdominal surgery divided the needed pedicle or perforators; perforator imaging is included when used by the surgeon.

Medical optimization: Nicotine cessation counseling, glycemic control, and assessment of obesity and other risk factors are documented in informed consent.

Inpatient setting required

Flap procedure requiring inpatient monitoring: The procedure is a free abdominal flap, including DIEP, SIEA, or free TRAM, or a pedicled TRAM requiring protocol flap monitoring and parenteral analgesia after surgery.
Additional inpatient complexity: The case involves bilateral reconstruction, combined mastectomy and reconstruction, or ASA physical status III or IV.

Observation or outpatient instead of inpatient

Observation or outpatient surgery is the appropriate level, and inpatient admission does not meet criteria, when ANY of the following applies.

Lower-acuity procedures: The procedure is implant or tissue-expander reconstruction without a flap, expander-to-implant exchange, or a revision without a new flap, including fat grafting, scar revision, flap debulking, nipple reconstruction, or contralateral reduction or mastopexy.

Intensive care unit level

Intensive care unit placement is appropriate when ANY of the following is present.

ICU criteria

Airway or ventilation instability: Invasive mechanical ventilation or a new or unstable artificial airway requires continuous critical-care airway expertise.
Hemodynamic instability: Persistent hypotension after initial fluid resuscitation or any titrated vasopressor or inotrope infusion is present.SBP < 90 mm Hg or MAP < 65 mm Hg
Hemorrhage or coagulopathy: Ongoing hemorrhage requires repeated transfusion, massive transfusion protocol activation, or coagulopathy correction with frequent laboratory titration.
Acute respiratory failure: Severe oxygenation or work-of-breathing impairment is present.SpO2 < 90% despite FiO2 >= 0.5; escalating high-flow or noninvasive ventilation; or RR > 30/min with increased work of breathing
Neurologic instability: Severe or worsening neurologic impairment or seizures requiring intravenous antiseizure titration is present.GCS <= 8; fall of >= 2 points; new focal neurologic deficit; or seizures requiring IV titration
Nursing intensity: Nursing assessment and intervention are needed every hour or more often, exceeding step-down staffing.Every hour or more often
Compromised flap re-exploration: Re-exploration of a compromised flap is associated with hemodynamic instability or transfusion need.

Step-down or intermediate-care level

Step-down or intermediate care is appropriate when the patient does not meet intensive care criteria and ANY of the following is present.

Intermediate-care criteria

Frequent assessments: Vital-sign or focused assessments exceed medical-surgical capability.Every 2 hours, or hourly for a limited protocol-defined period
Continuous monitoring or respiratory support: Continuous telemetry or pulse oximetry is required for documented arrhythmia, ischemia, or respiratory risk, or stable noninvasive or high-flow respiratory support is needed.
Monitored infusions: A non-titrated or slowly titrated infusion requires frequent monitoring.
Examples include insulin, heparin, or weaning antihypertensive infusion.
Recent ICU transfer: The patient is within the first 24 hours after ICU transfer and still needs closer monitoring than a medical-surgical unit provides.First 24 hours
Flap monitoring capability: Hourly flap checks are required and the medical-surgical unit cannot perform protocol flap monitoring.First 24 hours

Medical-surgical unit level

A medical-surgical unit is appropriate when the patient does not meet intensive care or step-down criteria and ANY of the following is present.

Medical-surgical criteria

Hemodynamic stability: The patient is stable off vasoactive infusions with vital-sign frequency of every 4 hours or less often clinically adequate.Off vasoactive infusions for at least 12 to 24 hours
Ongoing hospital-level services: Intravenous medications or fluids, parenteral analgesia, drain or wound care beyond home capability, or daily surgical reassessment remains necessary.
Routine flap recovery needs: The patient requires flap checks, transition from parenteral to oral analgesia, and mobilization with abdominal precautions.Flap checks every 2 to 4 hours after first 24 hours

Discharge readiness

The patient is ready for discharge when ALL of the following are met.

Physiologic stability: Temperature, heart rate, blood pressure, and oxygenation meet the stated limits.Temperature < 38.0 C for at least 24 hours; HR < 100/min; SBP >= 90 mm Hg or baseline; SpO2 >= 92% on room air or baseline home oxygen
Pain control: Pain is controlled on an oral or other home-deliverable regimen.
Nutrition: The patient tolerates an oral diet or has a stable enteral or parenteral nutrition plan with supplies and caregiver teaching completed.
Laboratory stability: Hemoglobin is stable without transfusion for 24 hours and electrolytes and renal function are acceptable or have an outpatient monitoring plan.No transfusion for 24 hours
Wound and drains: The wound is stable and drains are removed or have acceptable output with documented home drain teaching.
Mobility is at the expected post-procedure level or a suitable post-acute level of care is arranged.
Safe transition plan: Medications are reconciled; venous thromboembolism prophylaxis is planned according to risk; surgeon follow-up is arranged within 7 to 14 days; wound-care and return-precaution education is provided; and home health or durable medical equipment is arranged when needed.Surgeon follow-up within 7 to 14 days
Flap viability: The flap has a stable examination and Doppler signal.At least 24 hours
Abdominal donor site: The donor site is intact without hematoma or tension-related ischemia, and drains can be managed at home.
Ambulation: The patient ambulates independently with abdominal precautions.

Continued acute inpatient stay

Continued acute inpatient care is medically necessary when ANY of the following is documented.

Continued-stay criteria

Flap compromise requires re-exploration or revision.
Complication requiring inpatient treatment: Hematoma, infection, or donor-site wound complication requires inpatient treatment.
Intake or mobilization limitation: Pain or ileus prevents oral intake or mobilization after day 2.After day 2
Discharge criteria not met: Discharge readiness criteria are not met because of a documented, actively treated clinical problem.
Necessary inpatient intervention: A medically necessary procedure or intervention is scheduled within the next 24 hours and cannot safely be performed outpatient.Within next 24 hours

Does not meet criteria

The following scenarios do not meet medical-necessity criteria and are referred for physician review.

ICU monitoring only: Routine ICU admission solely for flap monitoring when the receiving unit can perform protocol flap checks.
Outpatient-capable procedure: Procedure safely performed in ambulatory surgery or hospital outpatient setting with same-day discharge or observation of 24 hours or less, with no inpatient criterion met.Observation <= 24 hours
Convenience preoperative day: Preoperative admission more than one day before surgery for scheduling or convenience without documented medical optimization need.> 1 day before surgery
Examples of optimization needs include dialysis, anticoagulation bridging, glucose or volume optimization, or nutrition repletion.
Stay after discharge readiness: Continued acute stay after all discharge-readiness criteria are met.
Awaiting disposition only: Continued stay solely awaiting post-acute placement, transportation, or caregiver availability without an active acute need.
Never a basis for retroactive denial of days already authorized.
Unexplained extended stay: Stay beyond the expected length-of-stay benchmark without a documented extended-stay trigger.Beyond benchmark
Request missing clinical information and refer for physician review.

Expected length of stay and extended-stay review

The expected length of stay is a planning benchmark, not a limit on covered days.

Extended-stay review

Extended-stay trigger: Flap compromise or re-exploration; hematoma; donor-site complication; ileus; pain uncontrolled on oral therapy; or medical complication.

Post-mastectomy reconstruction and symmetry procedures

Federal mandate.

WHCRA reconstruction coverage: Coverage includes all stages of post-mastectomy reconstruction and symmetry procedures.

The method of reconstruction is determined by the patient and attending physician.

Level of care and expected stay

Site-of-care and stay review.

Appropriate level of care: Flap monitoring does not require intensive care; uncomplicated cases are supported by a short-stay benchmark of 2 to 4 days.2 to 4 days for uncomplicated cases

The expected length of stay is a benchmark, not a coverage limit.

Implant-based reconstruction, fat grafting, and nipple reconstruction are outpatient procedures outside this policy and are not evaluated under these inpatient criteria.

Implant or tissue-expander reconstruction without a flap, expander-to-implant exchange, and revision procedures without a new flap—including fat grafting, scar revision, flap debulking, nipple reconstruction, or contralateral reduction or mastopexy—are not inpatient procedures under this policy.

Routine ICU admission solely for flap monitoring is the wrong level of care when the receiving unit can perform protocol flap checks. Flap monitoring alone does not support intensive care placement.

A preoperative admission more than one day before surgery for scheduling or convenience is not medically necessary unless a documented medical optimization need is present, such as dialysis, anticoagulation bridging, glucose or volume optimization, or nutrition repletion.

Continued acute inpatient care after all discharge-readiness criteria are met is not medically necessary at the acute level.

A continued stay solely while awaiting post-acute placement, transportation, or caregiver availability does not meet acute inpatient criteria when there is no active acute need. Such disposition barriers should be addressed through discharge planning.

The expected length of stay is a planning benchmark, not an automatic coverage limit. However, a stay beyond the benchmark requires a documented extended-stay trigger and supporting clinical information; without that documentation, the continued-stay criteria are not met as documented and the request is referred for physician review.

Coding and Clinical Threshold Reference

ICD-10-CM diagnosis codesICD-10

Z42.1	Reconstruction after mastectomy
Z90.10	Acquired absence of unspecified breast and nipple
Z90.11	Acquired absence of right breast and nipple
Z90.12	Acquired absence of left breast and nipple
Z90.13	Acquired absence of bilateral breasts and nipples
N65.0	Deformity of reconstructed breast
N65.1	Disproportion of reconstructed breast

ICD-10-PCS breast replacement codesICD-10

0HRT077	Breast replacement with DIEP, SIEA, or TRAM flap, right
0HRU077	Breast replacement with DIEP, SIEA, or TRAM flap, left
0HRV077	Breast replacement with DIEP, SIEA, or TRAM flap, bilateral
0HRT078	Breast replacement with DIEP, SIEA, or TRAM flap, right
0HRU078	Breast replacement with DIEP, SIEA, or TRAM flap, left
0HRV078	Breast replacement with DIEP, SIEA, or TRAM flap, bilateral
0HRT076	Breast replacement with DIEP, SIEA, or TRAM flap, right
0HRU076	Breast replacement with DIEP, SIEA, or TRAM flap, left
0HRV076	Breast replacement with DIEP, SIEA, or TRAM flap, bilateral

CPT and HCPCS procedure codesmixed

19364	Breast reconstruction with free flap
19367	Pedicled TRAM, single pedicle
19368	Pedicled TRAM, single pedicle with microvascular anastomosis (supercharging)
19369	Pedicled TRAM, double pedicle
S2068	Breast reconstruction with free flap

MS-DRG FY2027 v44mixed

579	Other skin, subcutaneous tissue and breast procedures with MCC
580	Other skin, subcutaneous tissue and breast procedures with CC
581	Other skin, subcutaneous tissue and breast procedures without CC/MCC
582	Mastectomy for malignancy with MCC
583	Mastectomy for malignancy without MCC
584	Breast biopsy, local excision and other breast procedures with MCC
585	Breast biopsy, local excision and other breast procedures without MCC

Revenue codesRevenue

0110-0129	Room and board
0110	Room and board
0111	Room and board
0112	Room and board
0113	Room and board
0114	Room and board
0115	Room and board
0116	Room and board
0117	Room and board
0118	Room and board

1–10 of 38

1/4

Revenue codesRevenue

0110-0129	Room and board
0200-0209	Intensive care
0206	Intermediate/step-down
0360-0369	Operating room services
0370	Anesthesia
0710	Recovery room

Revenue codes: individually listed codesRevenue

0110	Room and board
0111	Room and board
0112	Room and board
0113	Room and board
0114	Room and board
0115	Room and board
0116	Room and board
0117	Room and board
0118	Room and board
0119	Room and board

1–10 of 35

1/4

Discharge temperature threshold

Temperature thresholdBelow 38.0 C

Required durationAt least 24 hours

Medication conditionWithout antipyretic masking

Discharge heart-rate threshold

Heart-rate thresholdBelow 100/min

Applies toDischarge readiness

RequirementHeart rate must meet this limit as part of physiologic stability

Discharge systolic blood-pressure threshold

Systolic blood-pressure thresholdAt least 90 mm Hg

AlternativeDocumented baseline blood pressure

Applies toDischarge readiness and physiologic stability

Discharge oxygen-saturation threshold

Oxygen-saturation thresholdAt least 92%

Room-air conditionOn room air

AlternativeThe patient’s baseline home oxygen prescription

Flap viability discharge criterion

ExaminationStable flap examination

DopplerStable Doppler signal

Required durationAt least 24 hours

ICU hypotension threshold

Systolic blood pressure triggerBelow 90 mm Hg

Mean arterial pressure triggerBelow 65 mm Hg

Persistence conditionPersists after initial fluid resuscitation

ICU respiratory-failure thresholds

Oxygenation triggerSpO2 below 90% despite FiO2 of 0.5 or more

Ventilatory-support triggerEscalating high-flow or noninvasive ventilation

Respiratory-rate triggerRespiratory rate above 30/min with increased work of breathing

Neurologic deterioration threshold

Glasgow Coma Scale triggerGCS 8 or less

Change-from-baseline triggerFall of 2 or more points

Additional neurologic concernA new focal neurologic deficit or seizures requiring intravenous antiseizure titration also supports ICU placement

Hemoglobin decline red flag

Hemoglobin declineFall of 2 g/dL or more

Clinical concernBreast or abdominal hematoma, expanding swelling, or a significant hemoglobin decline

Required actionSurgeon evaluation; hematoma compressing the pedicle usually needs evacuation

Expected length of stay

Typical duration2 to 4 days

Applies toUncomplicated abdominal-flap reconstruction

Use of benchmarkPlanning benchmark, not a limit on covered days

Expected length of stay for uncomplicated cases

Benchmark2 to 4 days

Clinical contextUncomplicated cases

Coverage applicationThe expected stay is a benchmark rather than a coverage limit

Documentation, Submission, and Review Requirements

Documentation Required

Submit Inpatient Medical-Necessity Documentation

Submit documentation establishing that the inpatient admission meets the medical-necessity criteria for autologous abdominal-flap breast reconstruction. The record must support the procedure indication, reconstructive decision, medical optimization, and need for inpatient-level care.

Document the relationship to mastectomy, contralateral symmetry, or revision to autologous tissue for implant failure, capsular contracture, infection, or radiation injury.
Document shared decision-making between the patient and attending surgeon, including risks, alternatives such as implant reconstruction, and donor-site effects.
Document adequate abdominal donor tissue, relevant prior abdominal surgery or perforator concerns, and medical optimization including nicotine cessation, glycemic control, obesity, and other risk factors.
Document the planned flap procedure and the inpatient-setting rationale, such as protocol flap monitoring with parenteral analgesia, bilateral reconstruction, combined mastectomy and reconstruction, or ASA physical status III or IV.

Documentation Required

Document Indication, Risk, Procedure, and Planned Level of Care

Provide supporting clinical and surgical documentation for the indication, risk profile, procedure, and planned postoperative level of care before submitting the request.

Include the operative indication, diagnosis, staging or imaging, and surgical or multidisciplinary decision.
Include preoperative risk assessment, ASA physical status class, and relevant comorbidities.
List the planned procedures with CPT and ICD-10-PCS codes and explain the planned postoperative level of care.

Documentation Required

Submit Daily Inpatient Clinical Records

For each inpatient day, submit records showing an active acute problem requiring hospital-level services and the treatment plan. Include daily progress notes, vital signs, intake and output, relevant laboratory results, and procedure-specific monitoring records.

State the active acute problem and hospital-level service delivered each day.
Document the current treatment plan and clinically relevant response or changes.
Include flap and other procedure-specific monitoring records when applicable.

Documentation Required

Document Extended Stay and Discharge Readiness

For stays beyond the expected length of stay, document the specific trigger and supporting evidence. Also provide the discharge-readiness assessment and transition plan, including follow-up, education, and post-acute services.

Identify the clinical event or condition requiring the extended stay and provide objective supporting evidence.
Document discharge readiness, remaining barriers, follow-up arrangements, patient education, and any post-acute services.
An expected length of stay is a planning benchmark, not a limit on covered days; concurrent review applies to each continued-stay period.

Documentation Required

Document Reconstruction Decision and Flap Monitoring

Document the reconstruction decision and the monitoring needed for the selected flap procedure. The record must connect the mastectomy history or plan and shared decision-making to the reconstructive method and include flap-check records.

Include the history of mastectomy or planned mastectomy and whether reconstruction is immediate or delayed.
Record the shared decision on reconstructive method, including risks, alternatives, and donor-site effects.
Submit protocol flap-check records and other relevant procedure-specific monitoring.

Billing Rule

Support Requested Quantity and Duration

Support the requested quantity, units, and duration with clinical documentation. When only part of a request is supported, separate the supported portion from the unsupported increment for review.

Document the requested services, units, days, or duration and the clinical basis for each.
Approve the documentation-supported portion and refer only unsupported excess quantity or duration for physician review.

Denial Risk

Does Not Meet Medical-Necessity Criteria

Requests that do not meet inpatient, level-of-care, continued-stay, or discharge criteria do not meet medical-necessity criteria and must be referred for physician review. Automated systems and non-physician reviewers may not issue an adverse determination.

Refer requests lacking a qualifying inpatient-setting criterion or required clinical documentation.
Apply concurrent review to each continued-stay period and assess discharge readiness.
Do not issue an automated or non-physician adverse determination.

Denial Risk

ICU Used Solely for Flap Monitoring

Routine intensive care admission used solely for flap monitoring does not meet criteria when the receiving unit can perform protocol flap checks. Flap outcomes alone do not require ICU-level monitoring.

Identify ICU use that is limited to routine flap monitoring without qualifying ICU acuity.
Route the request for physician review when ICU-level services are not otherwise medically necessary.

Denial Risk

Lower-Acuity Procedure Submitted as Inpatient

Flag an inpatient submission when the procedure can be safely performed in an ambulatory surgery or hospital outpatient setting with same-day discharge or observation of 24 hours or less and no inpatient-setting criterion is met.

Examples include implant or tissue-expander reconstruction without a flap, expander-to-implant exchange, and revision without a new flap.
Revision examples include fat grafting, scar revision, flap debulking, nipple reconstruction, or contralateral reduction or mastopexy.
Route the request for physician review when the submitted inpatient level is not supported.

Denial Risk

Convenience Preoperative Admission

Flag a preoperative admission more than one day before surgery when it is for scheduling or convenience and the record does not show a medical optimization need requiring hospital-level services.

A qualifying optimization need may include dialysis, anticoagulation bridging, glucose or volume optimization, or nutrition repletion.
Do not treat a convenience day as medically necessary without documented clinical services and rationale.

Denial Risk

Continued Stay Without Active Acute Need

Flag continued inpatient days after all discharge-readiness criteria are met or when the stay is solely awaiting post-acute placement, transportation, or caregiver availability without an active acute need.

Document the active acute problem and hospital-level service supporting each continued-stay period.
Route unsupported continued stay for physician review and discharge planning.
Days already authorized are not retroactively denied solely because the stay later lacks an acute need.

Denial Risk

Extended Stay Without Documented Trigger

A stay beyond the expected length of stay requires a documented extended-stay trigger and supporting evidence. If the trigger is absent, request the missing clinical information and refer the continued-stay determination for physician review.

Identify the specific clinical complication, treatment need, or other acute event extending the stay.
Provide objective records supporting the trigger and its effect on discharge readiness.
An expected length of stay is a planning benchmark, not an automatic coverage limit.

Denial Risk

Requests Not Meeting Criteria Require Physician Review

Requests that fail medical-necessity or level-of-care criteria must be routed to physician review. Automated systems and non-physician clinical reviewers may approve in full or in part, but may never issue an adverse determination.

Refer non-qualifying inpatient, continued-stay, extended-stay, or discharge-related requests for physician review.
Do not deny a request through an automated system or non-physician review process.

Denial Risk

Adverse Determination Authority

Only a licensed physician of the same or similar specialty may issue an adverse determination, and only after offering the requesting provider a peer-to-peer discussion. The reviewing physician must also satisfy applicable plan and situs-state licensure, specialty, and medical-director requirements.

Offer the requesting provider a peer-to-peer discussion before the adverse determination.
Apply the applicable licensure, specialty, and medical-director requirements of the plan's situs state.

Billing Rule

Unsupported Excess Quantity or Duration

When the service meets criteria but the requested quantity, units, or duration exceed the documentation-supported amount, approve the supported portion and refer only the unsupported excess for physician review.

Separate supported services, units, or days from unsupported increments.
Do not issue an adverse determination for the supported portion.

Policy Scope and Coverage Context

This policy addresses the inpatient setting, level of care, and length of stay for immediate or delayed autologous breast reconstruction using abdominal flaps, including DIEP, SIEA, free TRAM, and pedicled TRAM flaps. It does not determine whether post-mastectomy reconstruction itself is covered; reconstruction after mastectomy is addressed under the Women's Health and Cancer Rights Act (WHCRA).

Flap Reconstruction Terminology

DIEP flap

Flap typeFree abdominal skin and fat flap based on deep inferior epigastric perforators

Muscle involvementSpares the rectus muscle

CPT reporting referenceCPT 19364

Pedicled TRAM

Flap typeTransverse rectus abdominis myocutaneous flap transferred on its superior epigastric pedicle

Single pedicleCPT 19367

Additional reporting referencesCPT 19368 for single pedicle with microvascular supercharging; CPT 19369 for double pedicle