C1789, Prosthesis, breast (implantable)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Inferred: clinical documentation of the indication for reconstruction (e.g., mastectomy or other reason for reconstruction) and patient-specific factors influencing choice of reconstruction (age, body composition, general health status, planned cancer treatment).
- Inferred: operative reports and clinical notes for initial reconstruction and any subsequent revision surgeries, including description of donor sites when autologous tissue is used.
- Inferred: documentation of asymmetry and clinical rationale for contralateral breast procedures (mastopexy, reduction, augmentation) to improve symmetry.
- Inferred: clinical documentation supporting implant-related complications (e.g., signs/symptoms and diagnosis of capsular contracture) when requesting capsulotomy or capsulectomy.
Key Coverage Criteria
- Breast reconstruction surgery rebuilds a breast's shape following a mastectomy or trauma
- may be performed immediately, be delayed or be completed in stages
- using autologous tissue taken from other areas of an individual's body (abdomen, back, buttocks, thighs)
- placing an artificial implant
- using a tissue expander if necessary, depending on the final desired breast size
- Breast reconstruction (autologous tissue or implants) depending on an individual's age, body composition, general health status, method of planned cancer treatment or other reason for reconstruction.
8 Active Policies
HUMANA-BREAST-PROCEDURES-SC-MEDICAID, Breast Procedures
ANTHEM-SURG.00023, SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
SUR716.011, Reconstructive Breast Surgery
BCBSIL-SUR716.011, Reconstructive Breast Surgery
BCBSMT-SUR716.011, Reconstructive Breast Surgery
Related Codes
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