L8600, Implantable breast prosthesis, silicone or equal
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; medical records documentation used for reviews (general statement from policy).
- Documentation of prior Mastectomy (operative report, pathology report, or other clinical record) to support reconstruction related to Mastectomy and WHCRA entitlement.
- Clinical documentation supporting diagnosis when reconstruction is for congenital disorders or severe breast disfigurement (e.g., diagnosis of Poland syndrome, Turner syndrome, amastia, radiation-related disfigurement).
- When requesting correction of inverted nipples, documentation of either: a documented history of chronic nipple discharge, bleeding, scabbing, or ductal infection; OR evidence that the inverted nipple is the result of a congenital anomaly.
- For treatment of lymphedema and related services, documentation of lymphedema diagnosis (e.g., I97.2 Postmastectomy lymphedema syndrome) and records supporting prescribed therapy (e.g., orders/therapy notes for complex decongestive physiotherapy, DME orders for lymphedema pumps, prescriptions/fit notes for compression sleeves, documentation of elastic bandages/wraps associated with medical treatment).
- For implant removal related to Allergan BIOCELL textured breast implants, documentation of the implanted device brand/type demonstrating Allergan BIOCELL textured implant exposure/implant history.
Key Coverage Criteria
- Treatment for post-mastectomy complications including postoperative infection(s).
- Breast reconstruction after Mastectomy with or without a diagnosis of cancer in accordance with the Women's Health and Cancer Rights Act of 1998 (reconstruction of the breast on which the Mastectomy was performed).
- Surgery and reconstruction of the contralateral breast to produce a symmetrical appearance, including nipple tattooing (per WHCRA).
- Prostheses (implanted and/or external) related to breast reconstruction post-mastectomy (per WHCRA).
- Treatment of physical complications of Mastectomy, including lymphedema (including complex decongestive physiotherapy (CDP), lymphedema pumps [considered durable medical equipment], compression lymphedema sleeves [considered a prosthetic device], elastic bandages and wraps associated with medically necessary treatments for complications of lymphedema).
- Breast reconstruction during or post Mastectomy and reconstruction for treatment of congenital disorder (e.g., Poland syndrome, Turner syndrome) or severe breast disfigurement (e.g., amastia, radiation) when considered reconstructive and medically necessary in accordance with InterQual CP: Procedures, Breast Reconstruction.
17 Active Policies
HUMANA-BREAST-PROCEDURES-SC-MEDICAID, Breast Procedures
ANTHEM-SURG.00023, SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
UHC-POL-breast-reconstruction, Breast Reconstruction
AMBETTER-CP.MP.107, Durable Medical Equipment and Orthotics and Prosthetics Guidelines
SUR716.011, Reconstructive Breast Surgery
BCBSIL-SUR716.011, Reconstructive Breast Surgery
BCBSIL-SUR716.009, Reconstructive Breast Surgery/Management of Breast Implants
BCBSMT-SUR716.011, Reconstructive Breast Surgery
BCBSMT-SUR716.009, Reconstructive Breast Surgery/Management of Breast Implants
BCBSNM-SUR716.011, Reconstructive Breast Surgery
BCBSNM-SUR716.009, Reconstructive Breast Surgery/Management of Breast Implants
BCBSOK-SUR716.011, Reconstructive Breast Surgery
BCBSOK-SUR716.009, Reconstructive Breast Surgery/Management of Breast Implants
REGENCE-MED153, Gender Affirming Interventions for Gender Dysphoria
REGENCE-SUR40, Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants
UMR-POL-UMR-breast-reconstruction, Breast Reconstruction
SUREST-POL-SUREST-breast-reconstruction, Breast Reconstruction
Related Codes
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