Breast Related Procedures

Coverage Summary

Policy 91545-R21 (Effective 2025-12-01, Last review 2025-11) is a consolidated coverage policy addressing a spectrum of breast-related procedures. Scope: defines medical necessity, exclusions, prior authorization, and coverage rules for implant removal, reconstruction and revision (including WHCRA-mandated reconstruction), reduction mammoplasty (lifetime limit of 1 per member), gynecomastia surgery, diagnostic and screening breast imaging (mammography/DBT/MRI/BSGI), bioimpedance for lymphedema, and related services across product lines with product-specific PA rules.

Highlights (one-sentence bullets):

- Consolidates previously separate policies including Breast Implants Explantation, Breast MRI, Breast Reconstruction and Revision Following Surgery for Breast Cancer, Male Gynecomastia, Mastectomy for Intractable Breast Pain, and Reduction Mammoplasty.

- References external criteria and mandates including InterQual, Evicore, and federal/state requirements such as WHCRA.

- Major categories covered or addressed include: implant removal (with Baker classification considerations and en bloc capsulectomy limits), breast reconstruction and revision (InterQual-guided; WHCRA mandated coverage for cancer-related reconstruction), reduction mammoplasty (subject to InterQual and a lifetime limit), gynecomastia surgery (with PA/photo requirements for Medicaid), breast imaging modalities (mammography/DBT/MRI/BSGI positions), and bioimpedance for breast cancer–related lymphedema.

Key thresholds and quick facts

Reduction mammoplasty lifetime limit1 per member

Autologous fat grafting limit150 cc per breast per procedure

Screening mammography frequency (Michigan law)Younger than 40: one per 5 years; Age 40+: one per year

Policy ID91545-R21

Coverage stancemixed

This policy consolidates multiple prior policies to provide unified guidance and rationale for breast-related care: implant removal (summarizing implant failure/rupture, capsular contracture and the commonly used Baker classification), reconstruction techniques (tissue expanders, implant and flap reconstructions including DIEP, TRAM, GAP, LD and others), gynecomastia assessment and grading (McKinney/Simon-derived grades I–IV), and imaging modality utility (screening/diagnostic mammography, DBT, MRI; roles and limitations of ultrasound, thermography, electrical impedance, and BSGI).

Clinical rationale excerpts: implant removal is indicated for complications such as extracapsular rupture, pain, infection or contracture (with contracture described by the Baker four-grade system); reconstruction options are described to restore appearance and function after mastectomy or injury with technique-specific considerations; gynecomastia is graded to guide surgical decision-making; and imaging choices are justified by relative sensitivity/utility and applicable coverage criteria (e.g., MRI screening when Evicore criteria are met).

Medical-Necessity Criteria (grouped by topic)

A. Breast Implant Removal

Covered/Not covered statements:

ALL of the following

Implant removal - medically necessary: Removal of breast implants placed for reconstruction after mastectomy, injury, congenital asymmetry, or augmentation mammoplasty is medically necessary according to InterQual criteria
Requesting physician should supply clinical information related to the degree of contracture (e.g., Baker classification) or describe the etiology of the pain
Not medically necessary for
- Breast malposition/asymmetry
- Baker Class I or II Contracture

Coverage Conditions & Supported Diagnoses

Covered when supporting diagnoses apply

Procedures listed are supported as medically necessary when accompanied by the listed ICD-10 diagnosis codes; all other indications must be prior authorized.

ALL of the following

Breast reconstruction/revision supporting diagnoses: Breast reconstruction and revision procedures are supported medical necessity when diagnosis codes C50.011 - C50.929, C79.81, D05.00 - D05.92, Z40.01, Z42.1, Z42.8, Z85.3, Z90.10 - Z90.13, Z98.82, N64.89, or relevant T85.* complication codes apply
These diagnoses must be present on the claim to support medical necessity
BIS supporting diagnosis: BIS (CPT 93702) is supported when ICD-10 codes C50-C50.929 or D05-D05.92 are present
Microsurgical lymph node transplantation billing guidance:

Coding (grouped by status)

Referenced policies and criteria sourcesmixed

91535	Cosmetic and Reconstructive Surgery Procedures (Priority Health Medical Policy #91535)
91508	Prophylactic Cancer Surgery (Priority Health Medical Policy #91508)
91447	Medical Necessity policy referenced for conventional measurement methods
91545-R21	This medical policy document identifier

Covered CPT/HCPCSCPT|HCPCSCovered

19328	Removal of intact breast implant
19330	Removal of ruptured breast implant, including implant contents
19318	Reduction Mammoplasty
11920	Tattooing, intradermal introduction of insoluble opaque pigments; 6.0 sq cm or less
11921	Tattooing; 6.1 to 20.0 sq cm
11922	Tattooing; each additional 20.0 sq cm
11970	Replacement of tissue expander with permanent implant
11971	Removal of tissue expander(s) without insertion of implant
19316	Mastopexy
19325	Breast augmentation; with implant

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Not covered CPT/HCPCSCPT|HCPCSNot Covered

97007	Mechanical scalp cooling, including individual cap supply
97008	Mechanical scalp cooling; including hair preparation, individual cap placement
97009	Mechanical scalp cooling; provided after discontinuation of chemotherapy, each 30 minutes
0694T	3-dimensional volumetric imaging and reconstruction of breast or axillary lymph node tissue
0857T	Opto-acoustic imaging, breast, unilateral
0945T	Intraoperative assessment for abnormal tissue using computer-aided fluorescence imaging
S8080	Scintimammography (radioimmunoscintigraphy of the breast)
78800	Radiopharmaceutical localization of tumor; limited area
78801	Radiopharmaceutical localization; multiple areas
0970T	Ablation, benign breast tumor, percutaneous, laser

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Breast imaging CPT/HCPCS (diagnostic and screening)CPT|HCPCS

76641	Ultrasound, breast, unilateral; complete
76642	Ultrasound, breast, unilateral; limited
77046	MRI, breast, without contrast; unilateral
77047	MRI, breast, without contrast; bilateral
77048	MRI, breast, without and with contrast; unilateral
77049	MRI, breast, without and with contrast; bilateral
77065	Diagnostic mammography, including CAD; unilateral
77066	Diagnostic mammography, including CAD; bilateral
77061	Digital breast tomosynthesis; unilateral
77062	Digital breast tomosynthesis; bilateral

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ICD-10 codes referenced as supporting medical necessityICD-10Covered

N64.9	Disorder of breast, unspecified
T85.44xA - T85.44xS	Capsular contracture of breast implant (initial to sequelae)
T85.828A - T85.828S	Fibrosis due to internal prosthetic devices, implants and grafts
T85.848A - T85.848S	Pain due to internal prosthetic devices, implants and grafts
T85.898A - T85.89S	Other specified complication of internal prosthetic devices, implants and grafts
N62	Hypertrophy of breast
C50.011 - C50.929	Malignant neoplasm of breast
C79.81	Secondary malignant neoplasm of breast
D05.00 - D05.92	Lobular carcinoma in situ / carcinoma in situ of breast
Z40.01	Encounter for prophylactic removal of breast

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CPT codes (general statement)CPT

No codes listed

Provider Actions & Prior Authorization

Prior Authorization

Photographic documentation required for PA

Photographic documentation must be submitted with all prior authorization requests. Photographs are a required accompaniment to PA submissions for breast-related procedures and should be included when requesting authorization for implant removal, reduction mammoplasty, gynecomastia evaluation, reconstruction/revision, and other covered procedures as indicated by product rules.

Implant removal requests
Reduction mammoplasty requests
Gynecomastia PA requests
Breast reconstruction/revision PA requests

Documentation Required

Implant removal documentation

For implant removal prior authorization, the requesting physician should supply clinical information related to the degree of capsular contracture (for example, Baker classification) or describe the etiology of the pain to support medical necessity for explantation and related procedures.

Background, Evidence & Definitions

Background: Policy 91545-R21 consolidates previously separate medical policies (Breast Implants Explantation, Breast MRI, Breast Reconstruction and Revision Following Surgery for Breast Cancer, Male Gynecomastia, Mastectomy for Intractable Breast Pain, and Reduction Mammoplasty) into a single coverage document to standardize medical necessity criteria and administrative requirements.

It references federal and state mandates (including the Women's Health and Cancer Rights Act) and external evidence/authorization sources such as InterQual and Evicore; photographic documentation is required with all prior authorization requests and product-specific PA rules apply.

Reference	Key finding
Autologous fat grafting systematic review (Seth et al., 2024)	35 studies, 3757 women; average injected 300 mL; avg retention 58%; complication rate 27.8%; patient satisfaction ~92%
BSCC consensus (2024) on en bloc capsulectomy	En bloc capsulectomy necessary only for established or suspected breast implant-associated cancer
Chang et al, 2021	Systematic review found evidence supporting vascular lymph node transplantation (grade 1B) but uncertainty between procedures (grade 2C)
NCCN Survivorship: Lymphedema (2023)	Recommends screening at-risk survivors by symptom assessment, clinical exam, and BIS if available
Selected study examples	Examples cited include studies on BIS for lymphedema and comparisons of tomosynthesis vs mammography (e.g., Whitworth, Vicini, Waldherr)

Definitions provided in the policy:

- Baker classification: a four-grade system describing capsular contracture severity from Grade I (soft) to Grade IV (hard, painful, distorted).

- En bloc capsulectomy: removal of the breast implant capsule with a margin of uninvolved tissue; per BSCC consensus and policy language it is medically necessary only for established or suspected breast implant–associated cancer and not indicated for routine indications.

- Bioimpedance spectroscopy (BIS): a multiple-frequency bioimpedance analysis method for detecting increases in tissue fluid for lymphedema assessment; the policy supports BIS for detection/monitoring of secondary, subclinical (Stage 0 or 1) breast cancer–related lymphedema.

- Lymphedema stages: Stage 0 (latent/subclinical), Stage 1 (spontaneously reversible), Stage 2 (irreversible with fibrosis), and Stage 3 (lymphostatic elephantiasis).

Medicare Determinations & LCD/NCD References

Name/Description	Number/Type
Breast Reconstruction Following Mastectomy	140.2 — NCD
Cosmetic and Reconstructive Surgery (various contractors)	L39506 / L38914 / L35090 / L33428 / L39051 — LCDs
Breast Reconstruction Following Mastectomy (duplicate listing)	NCD 140.2 — NCD

Not Covered / Experimental

Not covered CPT/HCPCSCPT|HCPCSNot Covered

97007	Mechanical scalp cooling, including individual cap supply with head measurement, fitting, and patient education - not covered
97008	Mechanical scalp cooling; including hair preparation, individual cap placement, therapy initiation, and precooling period - not covered
97009	Mechanical scalp cooling; provided after discontinuation of chemotherapy, each 30 minutes - not covered
0694T	3-dimensional volumetric imaging and reconstruction of breast or axillary lymph node tissue, each excised specimen, real-time intraoperative - not covered
0857T	Opto-acoustic imaging, breast, unilateral - not covered
0945T	Intraoperative assessment for abnormal (tumor) tissue using computer-aided fluorescence imaging - not covered
S8080	Scintimammography (radioimmunoscintigraphy of the breast) - not covered for any indication
78800	Radiopharmaceutical localization of tumor; limited area - not covered for the listed diagnoses
78801	Radiopharmaceutical localization; multiple areas - not covered for the listed diagnoses
0970T	Ablation, benign breast tumor, percutaneous, laser - not covered

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Revision History

clarification (is_material:false)

Photographic documentation must be submitted with all prior authorization requests; requirement repeated as a general requirement in multiple sections and noted for gynecomastia and prior authorization submission guidance.

2024material change (is_material:true)Latest

En bloc capsulectomy defined and medically necessary only for established or suspected breast implant–associated cancer; all other indications considered not medically necessary, aligned with 2024 BSCC consensus terminology and management guidance.