CurrentTexas Children's Health PlanPolicy 6203

Therapeutic and Reconstructive Breast Procedures Guideline

Customize your policy alerts

Sign up for texaschildrenshealthplan Policy 6203 alerts

Get alerted when Policy 6203 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This guideline governs prior authorization and medical-necessity review for surgical breast procedures, breast reconstruction, breast reduction, mastectomy, gynecomastia surgery, and breast prostheses for Texas Children's Health Plan members.

Policy Summary

PayerTexas Children's Health Plan

PolicyTherapeutic and Reconstructive Breast Procedures Guideline

Policy CodePolicy 6203

Change TypeNo material clinical or coverage change

Effective DateFeb 29, 2024

Next Review DateN/A

Key ActionObtain prior authorization for all surgical breast procedures, including breast prostheses, before services are provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

AllSurgical breast procedures and prostheses require authorization review

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentTexas Children's Health PlanPolicy 6203

Therapeutic and Reconstructive Breast Procedures Guideline

Customize your policy alerts

Sign up for texaschildrenshealthplan Policy 6203 alerts

Get alerted when Policy 6203 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerTexas Children's Health Plan

PolicyTherapeutic and Reconstructive Breast Procedures Guideline

Policy CodePolicy 6203

Change TypeNo material clinical or coverage change

Effective DateFeb 29, 2024

Next Review DateN/A

Key ActionObtain prior authorization for all surgical breast procedures, including breast prostheses, before services are provided.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

AllSurgical breast procedures and prostheses require authorization review

≤20 yearsAge limit for medically necessary pubertal gynecomastia mastectomy

1 yearRequired persistence period for qualifying reduction mammoplasty symptoms

1 kg/breastExpected tissue-removal threshold for reduction mammoplasty

Grade II–IVRequired gynecomastia classification for medically necessary mastectomy

Medical Necessity Criteria

Mastectomy and partial mastectomy

Covered when medically necessary to remove a breast or portion of a breast for one or more of the following indications:

Covered therapeutic or prophylactic indications

Therapeutic indications
- Developmental abnormality.
- Congenital defect.
- Trauma or injury to the chest wall.
- Primary or secondary malignancy of the breast.
- Carcinoma in situ of the breast.
Prophylactic mastectomy for moderate-to-high breast cancer risk
- Qualifying risk factor
  - Current or previous diagnosis of breast cancer.
  - Breast cancer in a mother, sister, or daughter, especially before age 50.
  - BRCA1 mutation.
  - BRCA2 mutation.
  - TP53 mutation.
  - PTEN mutation.

Pubertal gynecomastia mastectomy

Covered when ALL of the following criteria are met:

Pubertal gynecomastia criteria

Gynecomastia is classified as grade II, III, or IV under the American Society of Plastic Surgeons classification.
Age or pubertal maturity requirement
- The member is male and 20 years of age or younger.
- The member has evidence that puberty is near completion, demonstrated by 95% of adult height based on bone age and achievement of Tanner stage V.
When gynecomastia-inducing drugs or other substances have been identified as the cause, the member has discontinued them for at least one year.

Breast reconstruction

Covered in a single stage or multiple stages when ONE of the following situations applies:

Reconstructive breast procedure indications

Breast surgery of one or both breasts following mastectomy of one or both breasts.
Breast surgery to alter breast contour when significant abnormalities are related to trauma, congenital defects, infection, or other non-malignant disease.
Poland's syndrome with all defining findings
- Congenital absence or hypoplasia of the pectoralis major and minor muscles.
- Breast hypoplasia.
- Congenital partial absence of the upper costal cartilage.

Reduction mammoplasty

Covered when current applicable InterQual criteria are met and ALL of the following clinical and surgical requirements are satisfied:

Reduction mammoplasty criteria

Qualifying symptom persisting for at least one year
- Cervical or thoracic pain syndrome, including upper back and shoulder pain, has persisted for at least one year.
- Submammary intertrigo is refractory to conventional medications and measures used to treat intertrigo, or shoulder grooving with or without ulceration is unresponsive to conventional therapy, and the condition has persisted for at least one year.
- Thoracic outlet syndrome, including ulnar paresthesias from breast size, has persisted for at least one year and has not responded to at least three months of adequate conservative treatment.At least 3 months of adequate conservative treatment without response
Preoperative tissue-removal and symptom-relief assessment

External breast prostheses

Covered when ALL of the following criteria are met:

External breast prosthesis

The member is female.
The member has a history of a medically necessary mastectomy.

Prior authorization approval does not guarantee benefits or eligibility. Approval addresses only the medical necessity of the requested treatment or service; all services remain subject to applicable benefit limitations and exclusions. Providers must also comply with applicable state and federal requirements.

Requests that do not meet the criteria established by this guideline are referred to a TCHP Medical Director or Physician Reviewer for review, and the Denial Policy is followed.

Applicable Codes and Thresholds

Applicable Procedure CodesCPT

11970	Replacement of tissue expander with permanent implant.
11971	Removal of tissue expander(s) without insertion of implant.
19301	Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy).
19302	Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy.
19303	Mastectomy, simple, complete.
19305	Mastectomy, radical, including pectoral muscles.
19306	Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation).
19307	Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle.
19325	Breast augmentation with implant.
19340	Insertion of breast implant on same day of.

1–10 of 45

1/5

Reduction mammoplasty symptom duration

Required durationAt least 1 year

Applies toOne or more qualifying reduction mammoplasty symptoms

Qualifying examplesCervical or thoracic pain syndrome; refractory submammary intertrigo or shoulder grooving; or thoracic outlet syndrome

Thoracic outlet syndrome conservative treatment

ConditionThoracic outlet syndrome, including ulnar paresthesias from breast size

Required treatmentAdequate conservative treatment

Minimum duration without response

Authorization and Documentation Requirements

Prior Authorization

Obtain authorization before breast procedures

Prior authorization is required for all surgical breast procedures, including prostheses. Submit requests online, by fax, phone, or mail to the Utilization Management Department during normal business hours.

Prior Authorization

Authorize procedures for pediatric members

Prior authorization is required for members age 17 years and younger before proceeding with a surgical breast procedure.

Prior Authorization

Submit complete gynecomastia authorization documentation

Mastectomy for pubertal gynecomastia is a benefit with prior authorization for males age 20 years and younger. Include complete medical and family history, the treatment plan with planned procedure and surgical timeline, a physical examination identifying the affected breast or breasts, and supporting gynecomastia criteria.

Policy Background

This guideline addresses therapeutic breast surgery, including mastectomy and partial mastectomy, as well as breast reconstruction after mastectomy or significant breast abnormalities. It also covers reconstructive management of qualifying implant complications, reduction mammoplasty, and external breast prostheses. Reconstructive procedures may be performed in a single stage or multiple stages and may include implants, tissue expanders, autologous flaps, contralateral symmetry procedures, and tattooing.

Key Terms

Reconstructive Breast Procedures

PurposeProcedures that rebuild the normal contour of the breast to produce a more normal appearance

Breast coveredThe affected breast or the contralateral unaffected breast

ExamplesReconstructive surgery and implant insertion; muscle-tissue transposition; contralateral breast surgery for symmetry; and revision or removal of pre-existing cosmetic implants

Baker Class III contracture

TypeBreast implant complication

Defining findingVisible distortion of the breast

Classification

Policy Summary

PayerTexas Children's Health Plan

PolicyTherapeutic and Reconstructive Breast Procedures Guideline

Policy CodePolicy 6203

Change TypeNo material clinical or coverage change

Effective DateFeb 29, 2024

Next Review DateN/A

Key ActionObtain prior authorization for all surgical breast procedures, including breast prostheses, before services are provided.

SourceLink

On This Page

Lobular carcinoma in situ (LCIS).

Radiation therapy to the chest before age 30.

Recommendation by current National Comprehensive Cancer Network (NCCN) guidelines.

When a hormonal cause has been identified, there is evidence of resolution supported by appropriate test results and treatment for at least one year. Hormonal causes include hyperthyroidism, estrogen excess, prolactinomas, and hypogonadism.

A psychiatric assessment has been performed by a psychiatrist or psychologist.

The history and treatment plan document the planned surgical procedure and timeline.

Removal of an implant, with or without reimplantation, when the implant was originally placed after mastectomy, lumpectomy, or breast cancer treatment and has developed visible distortion caused by a Baker Class III contracture.

Removal of a saline-filled or alternative implant, with or without reimplantation, when it was originally placed after mastectomy, lumpectomy, or breast cancer treatment and has ruptured, become infected, or caused an inflammatory reaction.

Contralateral breast surgery to produce symmetry after removal and reimplantation of an implant originally placed after mastectomy, lumpectomy, or breast cancer treatment.

The surgeon's preoperative evaluation concludes that an appropriate amount of breast tissue will be removed from each breast based on the member's body surface area.
There is a reasonable prognosis of symptomatic relief.
The request documents the member's height and weight, the size and shape of the breast or breasts causing symptoms, the anticipated amount of tissue to be removed, and the minimum expected tissue weight from each breast.
At least 1 kg of breast tissue is anticipated to be removed from each breast, qualifying as an appropriate amount of tissue.At least 1 kg from each breast
Expected average tissue removal by height and weight
- Height less than 5 feet and weight less than 140 pounds: 300 grams per breast.
- Height 5 feet to 5 feet 4 inches and weight up to 180 pounds: 350 grams per breast.
- Height 5 feet 4 inches to 5 feet 7 inches and weight up to 220 pounds: 400 grams per breast.
- Height 5 feet 7 inches or above and weight 211 pounds or above: 500 grams per breast.

Minimum expected tissue removal

Minimum amountAt least 1 kg of breast tissue

Measurement basisTissue expected to be removed from each breast

QualificationAnticipated removal of at least 1 kg from each breast qualifies as an appropriate amount of tissue to be removed

Expected average tissue removal by height and weight

Less than 5 feet and less than 140 lb300 grams per breast

5 feet to 5 feet 4 inches and up to 180 lb350 grams per breast

5 feet 4 inches to 5 feet 7 inches and up to 220 lb400 grams per breast

5 feet 7 inches and above and 211 lb and up500 grams per breast

Documentation Required

Provide complete clinical documentation

Submit a complete history and physical examination documenting the chief complaint, diagnosis, history of the condition requiring surgery, member height and weight, relevant past medical and surgical history, family history, proposed surgical procedure, and treatment plan.

Documentation Required

Document screening and service location

For reduction mammoplasty, submit documentation of a mammogram negative for cancer within the past year and identify the location or facility where services will be provided, when applicable.

Documentation Required

Support reconstruction requests

For breast reconstruction, including tattooing, document the diagnosis causing the need for reconstruction, prior mastectomy date when appropriate, dates of prior reconstruction procedures when appropriate, proposed treatment plan and planned procedures, completion timeline, and any applicable complication.

Documentation Required

Document reduction tissue estimates

For reduction mammoplasty, document the member’s height and weight, the breast size and shape causing symptoms, anticipated tissue removal, and the minimum expected tissue weight from each breast. At least 1 kg of anticipated tissue removal from each breast qualifies as an expected appropriate amount.

Denial Risk

Address unmet criteria and benefit exclusions

Requests that do not meet the guideline criteria are referred to a TCHP Medical Director or Physician Reviewer for review under the Denial Policy. Prior authorization does not guarantee benefits or eligibility, and approved services remain subject to benefit limitations and exclusions.

Denial Risk

Prevent reduction mammoplasty denials

Reduction mammoplasty requests may fail medical-necessity review when qualifying symptoms have not persisted for at least one year, required conservative treatment has not failed, the expected tissue removal is not appropriate, or height, weight, and supporting clinical documentation are incomplete.

Denial Risk

Establish all gynecomastia criteria

Pubertal gynecomastia mastectomy requests may fail review when grade II, III, or IV gynecomastia is not established; age or near-completion of puberty is not documented; or required evidence of medication or substance discontinuation, hormonal-cause evaluation and treatment, psychiatric assessment, and the treatment plan is missing.

Baker Class III contracture

Poland's syndrome

ConditionA congenital syndrome involving breast and chest-wall development

Muscle findingCongenital absence or hypoplasia of the pectoralis major and minor muscles

Associated findingsBreast hypoplasia and congenital partial absence of the upper costal cartilage; all three findings must be present