CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Reconstructive Breast Surgery Coverage Following Mastectomy

Governs group and individual health plans' required coverage for breast reconstruction, contralateral surgery for symmetry, prostheses and treatment of physical complications (including lymphedema) following mastectomy; applies to plan participants and beneficiaries under applicable federal law.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyReconstructive Breast Surgery Coverage Following Mastectomy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 21, 1998

Next Review DateN/A

Key ActionDeliver written notice of the availability of mandated coverage to participants upon enrollment and annually thereafter.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3explicit coverage items required

annualwritten notice frequency

1999-01-01initial notice latest date

plan yearseffective timing for group plans

Required Coverage Provisions

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Mandatory coverage provisions

Covered when the participant or beneficiary is receiving benefits in connection with a mastectomy and elects breast reconstruction in connection with that mastectomy:

Required coverage elements: (1) all stages of reconstruction of the breast on which the mastectomy has been performed; (2) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (3) prostheses and treatment of physical complications of all stages of mastectomy, including lymphedema; all in a manner determined in consultation with the attending physician and the patient.

Coverage may be subject to annual deductibles and coinsurance consistent with other plan benefits.

The statute permits that mandated reconstruction coverage may be subject to the plan’s normal cost-sharing rules. Specifically, coverage may be provided "in a manner determined in consultation with the attending physician and the patient," and "such coverage may be subject to annual deductibles and coinsurance provisions as are consistent with those established for other benefits under the plan." The statutory text does not list any explicit clinical exclusions to the required items (reconstruction, contralateral surgery for symmetry, prostheses, and treatment of physical complications), so payment determinations should follow the described coverage elements and routine plan cost-sharing rather than rely on a statutory clinical exclusion.

Provider Requirements and Plan Practices

Billing Rule

Cost-sharing and Determination

Plans may apply annual deductibles and coinsurance to coverage for reconstruction, prostheses, and treatment of physical complications (including lymphedema) so long as those cost-sharing provisions are consistent with those applied to other benefits under the plan or coverage.

Cost-sharing (deductible and coinsurance) permitted if consistent with other plan benefits.

Documentation Required

Participant Notice Requirement

Plans must deliver written notice of the availability of reconstructive breast surgery coverage to participants and beneficiaries upon enrollment and annually thereafter. Additionally, a written notice describing the required coverage must be prominently positioned in plan literature or correspondence and transmitted either in the next mailing to the participant or beneficiary, as part of any yearly informational packet, or no later than January 1, 1999, whichever is earlier.

Notice on enrollment and annually thereafter.
Prominently positioned written notice in plan literature or correspondence.
Transmission timing: next mailing, yearly informational packet, or by January 1, 1999 (whichever is earlier).

Denial Risk

Prohibitions on Plan Practices

A plan or issuer may not deny eligibility, continued eligibility, enrollment, or renewal solely to avoid compliance with the reconstructive surgery coverage requirement. Plans also may not penalize, reduce, or limit reimbursement to an attending provider, or offer incentives to induce a provider to deliver care in a manner inconsistent with the required coverage. However, nothing prevents a plan or issuer from negotiating reimbursement levels or types with providers for care provided pursuant to this requirement.

Prohibition on denying enrollment/renewal solely to avoid compliance.
Prohibition on penalizing or reducing reimbursement, or providing incentives, to induce noncompliant provider behavior.
Plans may negotiate reimbursement amounts or types with providers for required services.

Documentation Required

Provider-Impact Highlights

Providers should be aware that the statute requires coverage for all stages of reconstruction of the mastectomy-affected breast, reconstruction of the contralateral breast for symmetry, and prostheses and treatment for physical complications (including lymphedema). Documentation of medical necessity and consultation with the attending physician and patient will support claims; plans may apply standard claims processing rules consistent with other benefits.

Coverage applies to: all stages of reconstruction of the affected breast; reconstruction of the other breast for symmetry; prostheses and treatment of physical complications including lymphedema.
Document clinical consultation and medical necessity in the medical record to support claims.
Apply standard plan claims determination and documentation requirements consistently with other benefits.

Definitions and Background

This federal statute requires that group health plans and issuers offering coverage in connection with group plans who provide medical and surgical benefits for mastectomy must also provide, for a participant or beneficiary receiving benefits in connection with a mastectomy who elects breast reconstruction, coverage for: all stages of reconstruction of the mastectomy breast; surgery and reconstruction of the other breast to achieve symmetry; and prostheses and treatment of physical complications of the mastectomy (including lymphedema). These services must be provided in consultation with the attending physician and the patient, and plans must deliver written notice of the availability of such coverage upon enrollment and annually thereafter.

inv-08: All stages of reconstruction

Scope of coverageAll stages of reconstruction of the breast on which the mastectomy has been performed, as determined in consultation with the attending physician and the patient.

Contralateral proceduresSurgery and reconstruction of the other breast to produce a symmetrical appearance.

Timing conditionCoverage applies when the participant or beneficiary is receiving benefits in connection with a mastectomy and elects breast reconstruction in connection with that mastectomy.

Cost-sharing allowanceCoverage may be subject to annual deductibles and coinsurance provisions consistent with those established for other benefits under the plan.

Decision-makingExtent and manner of reconstruction to be determined in consultation with the attending physician and the patient.

inv-09: Physical complications of mastectomy

Included conditionsPhysical complications of mastectomy, including lymphedema, are covered when treatment is required in connection with the mastectomy.

ProsthesesProstheses related to the mastectomy are included as part of required coverage.

Determination of careTreatment for physical complications is to be provided in a manner determined in consultation with the attending physician and the patient.

Cost-sharingCoverage for treatment of physical complications may be subject to annual deductibles and coinsurance consistent with other plan benefits.