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ModifiedExcellus Health Plan IncPolicy 10.01.01

Breast Reconstruction Surgery and Prophylactic Breast Cancer Risk-Reducing Mastectomy

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Medical-necessity coverage for reconstructive breast surgery during or after mastectomy and prophylactic risk-reducing mastectomy, including related reconstruction, symmetry procedures, prostheses, and treatment of post-mastectomy complications.

Policy Summary

PayerExcellus Health Plan Inc

PolicyBreast Reconstruction Surgery and Prophylactic Breast Cancer Risk-Reducing Mastectomy

Policy CodePolicy 10.01.01

Change TypeModified

Effective DateAugust 20, 2026

Next Review DateAugust 1, 2027

Key ActionVerify that the member's product covers the requested service before applying the medical policy criteria.

SourceLink

POLICY UPDATE CHANGES

The policy history documents a March 25, 2026 coding edit that added various ICD-10 codes and removed ICD-10 code Z90.10.

2Covered service categories

4High-risk factors for prophylactic mastectomy

6Covered reconstruction or related service examples

3Alternatives to conventional risk-reducing mastectomy

Z90.10ICD-10 code removed

Medical Necessity and Coverage Criteria

Reconstruction during or after mastectomy

Reconstructive breast surgery is considered medically appropriate during or after surgical mastectomy, including partial mastectomy, for benign or malignant disease. All stages of reconstruction may be included.

Post-mastectomy reconstruction: The individual has undergone or is undergoing surgical mastectomy, including partial mastectomy such as lumpectomy, segmentectomy, or quadrantectomy, for benign or malignant disease.

Reconstructive breast surgery during or after mastectomy is medically appropriate.

Covered reconstruction and related services: Services may include breast implants; abdominal flap reconstruction; chest wall reconstruction; nipple/areola reconstruction and tattooing; surgery for symmetry of the contralateral breast; basic breast prostheses and mastectomy bras; and treatment of physical complications of mastectomy, including lymphedema.

These are non-exhaustive examples, and all stages of reconstruction may be included.

Prophylactic risk-reducing mastectomy

A risk-reducing mastectomy is considered medically appropriate prophylactic treatment when ANY one of the following high-risk breast cancer factors is present.

Policy Summary

PayerExcellus Health Plan Inc

PolicyBreast Reconstruction Surgery and Prophylactic Breast Cancer Risk-Reducing Mastectomy

Policy CodePolicy 10.01.01

Change TypeModified

Effective DateAugust 20, 2026

Next Review DateAugust 1, 2027

Key ActionVerify that the member's product covers the requested service before applying the medical policy criteria.

SourceLink

On This Page

Federal and state reconstructive coverage mandates

Coverage is supported by the federal and New York State reconstructive coverage mandates described in the policy guideline.

Mandated reconstructive coverage context: For group health plans, whether insured or self-funded, that provide medical and surgical benefits, the Federal Women's Health and Cancer Rights Act of 1998 and the New York Insurance Law mandate coverage of all stages of reconstructive surgery for individuals who have or have not been diagnosed with breast cancer, in the manner determined appropriate by the attending physician and the patient.

Mandated coverage can include surgery and reconstruction of the contralateral breast to produce a symmetrical appearance, chest wall reconstruction, prostheses, treatment of physical complications following mastectomy, and prophylactic mastectomy.

Billing and Diagnosis Coding

CPT CodesCPT

11920	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less.
11921	6.1 to 20.0 sq cm each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure).
11922	Code for primary procedure.
13100	Repair, complex, trunk; 1.1 cm to 2.5 cm.
13101	Repair, complex, trunk; 2.6 cm to 7.5 cm.
14000	Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less.
14001	Adjacent tissue transfer or rearrangement, any area; defect 10.1 sq cm to 30 sq cm.
14301	Adjacent tissue transfer, intermediate, of any pedicle flap (abdomen to wrist, walking tube), any location; defect 30.1 sq cm to 60.0 sq cm.
15738	Muscle, myocutaneous, or fasciocutaneous flap; lower extremity.
15771	Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50cc or less injectate.

1–10 of 37

1/4

HCPCS CodesHCPCS

L8001	Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type.
L8002	Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type.
L8600	Implantable breast prosthesis, silicone or equal.
S2066	Breast reconstruction with gluteal artery perforator (GAP) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral.
S2067	Breast reconstruction of a single breast with 'stacked' deep inferior epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator (GAP) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateral.
S2068	Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site, and shaping the flap into a breast.

ICD10 CodesICD-10

C48.1	Malignant neoplasm of specified parts of peritoneum.
C50.A0	Malignant inflammatory neoplasm of unspecified breast.
C50.A1	Malignant inflammatory neoplasm of right breast.
C50.A2	Malignant inflammatory neoplasm of left breast.
C50.011-	Malignant neoplasm of nipple and areola (code range).
C50.021	Malignant neoplasm of nipple and areola, right male breast.
C50.022	Malignant neoplasm of nipple and areola, left male breast.
C50.029	Malignant neoplasm of nipple and areola, unspecified male breast.
C50.111-C50.119	Malignant neoplasm of central portion of female breast (code range).
C50.121	Malignant neoplasm of central portion of right male breast.

1–10 of 60

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Removed ICD-10 CodeICD-10

Z90.10

ICD-10 code removed from the policy; specific description is not stated

Policy Background

This policy addresses reconstructive breast surgery during or after surgical mastectomy, including partial mastectomy such as lumpectomy, segmentectomy, or quadrantectomy for benign or malignant disease. Reconstruction may occur in a single stage or through multiple stages and may include implants, abdominal or other autologous flap reconstruction, chest wall reconstruction, nipple/areola reconstruction and tattooing, surgery to achieve symmetry of the opposite breast, basic breast prostheses and mastectomy bras, and treatment of physical complications such as lymphedema.

The policy also addresses prophylactic risk-reducing mastectomy for individuals with specified high-risk factors, including lobular carcinoma in situ, a known BRCA1 or BRCA2 variant, certain other high-risk gene variants, or chest radiotherapy received between ages 10 and 30 years. Covered reconstruction-related services and techniques may be considered across all stages of care, subject to the applicable medical-necessity criteria and the member's benefit coverage. Federal and New York requirements described in the policy support coverage of reconstructive surgery and related services, including contralateral surgery for symmetry, prostheses, treatment of post-mastectomy complications, and prophylactic mastectomy.

Key Terms

Reconstructive breast surgery

DefinitionA surgical procedure designed to restore the normal appearance of the breast after surgery, accidental injury, or trauma.

TimingMay be performed in a single stage or in several stages or phases, either during or after removal of breast tissue.

ExamplesMay include prosthetic implants, flap reconstruction, chest wall reconstruction, nipple/areola reconstruction and tattooing, and surgery to achieve symmetry of the opposite breast.

Conventional mastectomy

DefinitionA surgical procedure that removes the entirety of the breast tissue, the skin overlying the breast, and the nipple-areola complex.

Breast tissue removedThe entire breast tissue is removed.

Nipple-areola complexThe skin overlying the breast and the nipple-areola complex are removed as part of the procedure.

Risk-reducing mastectomy

DefinitionSurgical removal of both breasts to reduce cancer risk in individuals considered very high risk.

Alternative namesAlso referred to as a preventative or prophylactic mastectomy.

TechniquesMay be performed as a total mastectomy, removing the nipple and areola, or by a nipple-sparing technique that preserves them.

Nipple-sparing mastectomy

DefinitionA mastectomy technique that preserves the nipple and areola.

Preserved structuresThe nipple and areola remain intact during the mastectomy.

Reconstruction contextThis technique may be used as an alternative to total mastectomy and allows for more natural-looking breasts after reconstruction.

CRRM

AbbreviationCRRM.

Full termContralateral risk-reducing mastectomy.

Clinical contextFor patients with breast cancer interested in CRRM, physicians should discuss nipple-sparing mastectomy as a reasonable oncologic option when applicable.

E/I

AbbreviationE/I.

Full termExperimental/Investigational.

Policy designationE/I is the policy abbreviation for Experimental/Investigational.

NMN

AbbreviationNMN.

Full termNot medically necessary/appropriate.

Policy designationNMN is the policy abbreviation for Not medically necessary/appropriate.