Breast Reconstructive Surgery, Reduction Mammoplasty, and Implant Management
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Medicare policy governing coverage, coding, and billing for breast reconstruction, reduction mammoplasty, and implant management for Providence Medicare members; clarifies reconstructive vs cosmetic determinations, coding guidance, and prior authorization considerations.
No material clinical or coverage changes in this revision.
Coverage Determinations
Medicare coverage determination logic
Coverage is determined by whether procedures are reconstructive (medically necessary) versus cosmetic (excluded); applicable CMS NCDs/LCDs and WHCRA protections apply.
When review determines a procedure is cosmetic, deny as not medically necessary/ not covered per Medicare Benefit Policy Manual, Chapter 16, §120.
Document clinical indication, relevant CMS reference(s), and, where applicable, WHCRA applicability. For procedures without an established specific code, unlisted codes will be reviewed at claim level for medical necessity, coding, and pricing.
Cosmetic surgery and services incurred in connection with cosmetic surgery are excluded from Medicare coverage. The Medicare Benefit Policy Manual (Chapter 16, §120) and Title XVIII, Section 1862(a)(1)(P)(10)(4) specify that procedures directed solely at improving appearance are not covered, except when required for the prompt repair of an accidental injury or to improve function of a malformed body member. Documented reconstructive intent and applicable CMS guidance must be used to determine coverage.
All unlisted codes are reviewed at the claim level for medical necessity, correct coding, and pricing. If an unlisted code is submitted for a service that is non-covered under this policy, the claim will be denied as not covered. To avoid post-service denial when an unlisted code may represent a potentially covered service, prior authorization is recommended.
Some skin and tissue substitute products (including surgical mesh and certain acellular dermal matrices) lack FDA clearance or approval for use in breast reconstruction. Because the FDA has not reviewed potential benefits and risks for these uses, requests for those products in the context of breast reconstruction may be denied. The safety and efficacy of products not cleared for breast reconstruction have not been adequately evaluated; surgeons are encouraged to use products with proven efficacy for this indication and the plan will apply its coverage criteria when FDA clearance does not include breast reconstruction.
CPT/HCPCS Codes and Status
| 11920 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color |
| 11921 | Tattooing, defects of skin, including micropigmentation; 6.0 sq cm or less |
| 11922 | Tattooing, defects of skin, including micropigmentation; 6.1 to 20.0 sq cm |
| 11970 | Replacement of tissue expander with permanent implant (list separately in addition to code for primary procedure) |
| 11971 | Replacement of tissue expander with permanent implant / Removal of tissue expander(s) without insertion of implant |
| 19316 | Mastopexy |
| 19318 | Breast reduction |
| 19325 | Breast augmentation with implant |
| 19328 | Removal of intact breast implant |
| 19330 | Removal of ruptured breast implant, including implant contents |
| 19342 | Replacement of breast implant on separate day from mastectomy |
| 19350 | Insertion or replacement of breast implant on separate day from mastectomy |
| 19355 | Nipple/areola reconstruction |
| 19357 | Correction of inverted nipples |
| 19361 | Tissue expander placement in breast reconstruction, including subsequent expansion(s) |
| 19364 | Breast reconstruction; with latissimus dorsi flap |
| 19367 | Breast reconstruction; with single-pedicled transverse rectus abdominis |
| 19368 | Breast reconstruction; with single-pedicled TRAM flap, requiring separate microvascular anastomosis (supercharging) |
| 19369 | Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap |
| 19370 | Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy |
| 19380 | Revision of reconstructed breast (eg, significant removal of tissue, re- advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction) |
| 19396 | Preparation of moulage for custom breast implant |
| S2066 | Breast reconstruction with gluteal artery perforator (GAP) flap, unilateral (CMS-assigned Status 'I' code) |
| S2067 | Breast reconstruction of a single breast with 'stacked' DIEP and/or GAP flaps, unilateral (CMS-assigned Status 'I' code) |
| S2068 | Breast reconstruction with DIEP or SIEA flap, unilateral (CMS-assigned Status 'I' code) |
Prior Authorization, Documentation, and Billing Guidance
Prior authorization required when Medicare criteria for skin/tissue substitutes are not established
When Medicare coverage criteria are not fully established for use of skin or tissue substitutes in breast reconstruction, Company criteria are applied and pre-service organizational determination (prior authorization) may be required for items potentially excluded by Medicare or the member EOC. Providers should submit a prior authorization request for skin/tissue substitute products when product-specific Medicare guidance is absent to ensure coverage determination before service.
- Company criteria apply when Medicare coverage criteria are 'not fully established' for skin/tissue substitutes.
- Pre-service organizational determination (prior authorization) may be required to avoid post-service denials or benefit exclusions.
Recommend prior authorization for unlisted or potentially covered codes
Prior authorization is recommended when unlisted codes or services that might be covered are submitted to avoid post-service denial; provider contracts and member benefits may also affect review requirements.
- If an unlisted code is submitted for potentially covered services, prior authorization is recommended to avoid post-service denial.
- Provider contracts, member benefits, eligibility, and utilization review may affect whether pre-service review is required.
Unlisted code use triggers claim-level medical necessity review
If no specific CPT or HCPCS code exists for a procedure and an unlisted code is used, the submission will be reviewed at the claim level for medical necessity, correct coding, and pricing.
- Unlisted codes should be used only if no other CPT or HCPCS code is available.
- Unlisted-code reviews occur at claim level and include medical necessity, coding accuracy, and pricing determinations.
When to use unlisted codes and request review/prior authorization
Use unlisted codes only when no specific CPT/HCPCS code exists and be prepared for claim-level review; submit full supporting documentation (see documentation callouts) and consider prior authorization when service may be potentially covered.
- If no specific code exists, report an appropriate unlisted CPT/HCPCS code and include detailed clinical documentation.
- Consider prior authorization for unlisted submissions that may represent potentially covered services to reduce risk of denial.
Document reconstructive versus cosmetic indication with CMS references
Document whether the procedure is reconstructive (medically necessary) or cosmetic; include applicable CMS references (NCDs/LCDs, WHCRA) and clinical rationale because Medicare coverage depends on reconstructive versus cosmetic determination.
- Cite NCD 140.2 and any applicable LCDs or CMS guidance used to support reconstructive indications.
- Document clinical details showing congenital defect, trauma, infection, tumor, disease, or WHCRA-related indication (eg, mastectomy) to support reconstructive intent.
Provide full documentation when submitting unlisted codes to support medical necessity and pricing
For any unlisted code submission, include documentation that supports medical necessity, correct coding, and pricing (clinical notes, operative reports, reasoning why no other code applies) because all unlisted codes are reviewed at the claim level.
- Provide operative reports, detailed procedure descriptions, and clinical justification demonstrating medical necessity.
- Explain why no specific CPT/HCPCS code applies to support accurate coding and pricing during claim review.
Procedures determined cosmetic are excluded and at risk for denial
Services determined to be cosmetic are excluded from Medicare coverage and may be denied under Title XVIII, Section 1862(a)(1)(P)(10)(4); providers should ensure documentation demonstrates a reconstructive or medically necessary purpose to avoid cosmetic-exclusion denials.
- Cosmetic surgery and related expenses are not covered except for prompt repair of accidental injury or improvement of function of a malformed body member.
- Document therapeutic or functional indications to establish coverage under Medicare.
Do not submit HCPCS S2066–S2068 for Medicare — use CPT 19364 or an unlisted code
HCPCS S-codes S2066, S2067, and S2068 are assigned CMS Status 'I' and are not valid for Medicare purposes; providers must use alternate CPT/HCPCS codes (eg, CPT 19364) or an appropriate unlisted code because S2066–S2068 are not accepted for Medicare claim submission.
- S2066–S2068 have Status Indicator 'I' ('Not valid for Medicare purposes') and are not recognized for claim submission.
- Use CPT code 19364 when appropriate or report an unlisted code if no specific code exists.
Unlisted codes for non-covered services will be denied
If an unlisted code is submitted for services that are non-covered under this policy, the claim will be denied as not covered; providers should either select an appropriate covered code or seek prior authorization if the service may be potentially covered.
- Unlisted codes submitted for non-covered services addressed in this policy will be denied as not covered.
- Prior authorization is recommended when the service may be potentially covered to avoid post-service denial.
Clinical Background
Reconstructive surgery is performed on abnormal structures caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease, typically to improve function and sometimes to restore appearance. Coverage determinations hinge on whether the procedure is reconstructive (medically necessary) versus cosmetic (excluded). Additionally, the Women's Health and Cancer Rights Act (WHCRA) requires coverage for all stages of breast reconstruction following mastectomy, including procedures to achieve symmetry and treat complications; relevant CMS NCDs and LCDs should be considered when making coverage decisions.
Definitions and Terminology
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