G6015, Intensity modulated treatment delivery, single or multiple fields/arcs,via
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Documentation Required
- Pre-operative mammogram for women aged 40 years and older (the only criterion identified by Nguyen et al as supportable; cited in text).
- For adolescents: documentation that breast growth has ceased and that breast size has been stable for at least 12 months prior to reduction mammaplasty (ASPS/ACOG guidance cited).
- Counseling documentation: counseling regarding risks associated with obesity and smoking and recommendation to lose weight and stop smoking prior to elective reduction mammoplasty (studies cite increased complications with smoking and obesity).
- When applicable, pathology/histopathology reporting for reduction mammoplasty specimens (example: contralateral reduction mammoplasty specimens in breast cancer patients revealed occult/high-risk lesions in some cases).
Key Coverage Criteria
- C. Breast asymmetry: referral to CPB 0185 (Breast Reconstructive Surgery) for medical necessity criteria for surgery to correct breast asymmetry.
- Applicable ICD-10 diagnoses listed as covered when selection criteria are met: G56.00–G56.93 (mononeuropathies of upper limb / upper extremity paresthesia); I96 (gangrene / tissue necrosis); L98.491–L98.494 (non-pressure chronic ulcer of skin of other sites); N62 (hypertrophy of breast); N64.89 (other specified disorders of breast / soft tissue infection).
- CPT code listed as covered if selection criteria are met: 19318 (reduction mammaplasty).
- Reduction mammoplasty or breast reduction surgery reduces the volume and weight of the female breasts by removing excess fat, glandular tissue and skin.
- Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders.
- Aetna has considered this procedure medically necessary in women with excessively large breasts because it seems logical, even in the absence of firm clinical trial evidence, that this excessive weight would contribute to back and shoulder pain, and that removal of this excessive breast tissue would provide substantial pain relief, reductions in disability, and improvements in function.
11 Active Policies
EVICORE-RADIATION-ONCOLOGY-CODING-MANUAL, EviCore Radiation Oncology Coding Manual
AETNA-CPB-0017, Breast Reduction Surgery and Gynecomastia Surgery
AMBETTER-CP.MP.69, Intensity-Modulated Radiotherapy
AMBETTER-CP.MP.251, Radiation Therapy for Skin Cancer
REGENCE-MED166, Intensity Modulated Radiotherapy (IMRT) for Breast Cancer
Related Codes
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