19366
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- When billing, providers must use the most appropriate codes as of the effective date of the submission.
- Claims submitted for services that are not accompanied by covered code(s) under the applicable Coverage Policy will be denied as not covered.
- Coverage determinations in each specific instance require consideration of: 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies; and 4) the specific facts of the particular situation.
- Reimbursement is only provided if a requested service(s) is submitted in accordance with the relevant criteria outlined in the applicable Coverage Policy, including covered diagnosis and/or procedure code(s).
Key Coverage Criteria
- Coverage for breast reconstruction and breast prostheses following mastectomy or lumpectomy is governed by federal and/or state mandates.
- Coverage for breast reconstruction services following mastectomy and lumpectomy is available to both females and males.
- A diagnosis of breast cancer is not required for breast reconstruction services to be covered, and the timing of reconstructive services is not a factor in coverage.
- Breast reconstruction following mastectomy or lumpectomy is considered medically necessary for EITHER of the following: procedures performed on the diseased/affected breast (i.e., breast on which the mastectomy/lumpectomy was performed), including: areolar and nipple reconstruction (e.g., correction of inverted nipple).
- Breast reconstruction following mastectomy or lumpectomy is considered medically necessary for EITHER of the following: procedures performed on the diseased/affected breast, including: areolar and nipple tattooing.
- Breast reconstruction following mastectomy or lumpectomy is considered medically necessary for EITHER of the following: procedures performed on the diseased/affected breast, including: autologous fat transplant (i.e., liposuction, lipoinjection, lipofilling, lipomodeling).
5 Active Policies
AMBETTER-CP.MP.31 — Cosmetic and Reconstructive Procedures
CIGNA-0178 — Breast Reconstruction Following Mastectomy or Lumpectomy - (0178)
HUMANA-BREAST-RECONSTRUCTION-OH-MEDICAID — Breast Reconstruction - MEDICAID - OHIO
ANTHEM-SURG.00023 — SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
REGENCE-SUR40
Related Codes
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