Augmentation Mammoplasty (Breast Enlargement) Coverage Criteria
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Defines coverage and prior authorization requirements for augmentation mammoplasty (breast enlargement) including use of autogenous tissue or implants; applies to members covered by the Executive Office of Health and Human Services.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Covered indications (reconstructive)
Covered when ALL of the following are met
Prior authorization required and valid for 12 months
Procedures performed for solely cosmetic purposes are not covered.
Augmentation mammoplasty performed solely for cosmetic purposes is considered not medically necessary and is not covered.
Provider Requirements and Prior Authorization
Prior authorization required; valid 12 months
Prior authorization is required for augmentation mammoplasty. If prior authorization is issued, it is valid for 12 months from the date of issuance.
Include coverage scenario and supporting evidence with PA request
Follow the policy's coverage guidelines when submitting requests: enumerate which of the two covered scenarios applies (subcutaneous mastectomy with immediate/delayed prosthesis, or previous mastectomy with symmetry procedure) and include supporting clinical evidence with the authorization request.
- Indicate whether the request is for: (1) benign disease with subcutaneous mastectomy and immediate or delayed prosthesis, or (2) previous mastectomy for benign or malignant disease including treatment of the unaffected breast for symmetry.
- Submit supporting clinical evidence that documents the indicated scenario with the prior authorization submission.
Required clinical documentation (evidence of covered indication)
Provide documented clinical evidence demonstrating one of the covered indications: either (1) surgery for benign disease when a subcutaneous mastectomy is performed with immediate or delayed prosthesis, or (2) a previous mastectomy for benign or malignant disease including treatment of the unaffected breast to provide symmetry with the breast on which the radical or modified mastectomy was performed.
Denial risk: solely cosmetic procedures are not covered
Requests for augmentation mammoplasty performed solely for cosmetic purposes will be denied because procedures performed for solely cosmetic purposes are not covered.
Key Definitions
Background
Augmentation mammoplasty is the surgical enlargement of the breast. Enlargement may be achieved using autogenous tissue (for example, a muscle flap graft) or by insertion of a liquid-filled prosthesis.
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