N60.19 — Diffuse cystic mastopathy of unspecified breast
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Pathology and oncologic records as applicable (e.g., cancer diagnosis, BRCA status, mastectomy specimen details) when reconstruction is performed for oncologic indications.
- Pre-operative imaging and planning records when utilized: CTA or MRA for perforator mapping, MRI/CT when used for volumetric analysis, 3D surface imaging and any 3D-printed templates used for operative planning.
- Documentation of prior or planned radiotherapy (pre-operative or post-operative XRT) and counseling regarding increased complication risk with EIBR when XRT present.
- Documentation of patient-specific risk factors (BMI/obesity, smoking status, comorbidities) that influence technique selection and perioperative risk counseling.
Key Coverage Criteria
- Reconstructive breast surgery after a medically necessary mastectomy.
- Reconstructive breast surgery after a medically necessary lumpectomy that results in a significant deformity (i.e., mastectomy or lumpectomy for treatment of or prophylaxis for breast cancer and mastectomy or lumpectomy performed for chronic, severe fibrocystic breast disease, unresponsive to medical therapy).
- Harvesting (via lipectomy or liposuction) and grafting of autologous fat as a replacement for implants for breast reconstruction, or to fill defects after breast conservation surgery or other reconstructive techniques (medically necessary).
- Medically necessary procedures to correct breast asymmetry that is due to a medically necessary mastectomy or a medically necessary lumpectomy that results in a significant deformity (including medically necessary procedures on the non-diseased/contralateral breast to produce a symmetrical appearance).
- Prompt repair of breast asymmetry due to trauma (subject to CPB 0031 - Cosmetic Surgery criteria for cosmetic disfigurement due to trauma).
- Medically necessary breast reconstructive procedures including (explicitly listed): capsulectomy; capsulotomy; implantation of FDA-approved internal breast prosthesis; mastopexy; insertion of breast prostheses; use of tissue expanders; reconstruction with latissimus dorsi (LD) myocutaneous flap; Ruben’s flap; superficial inferior epigastric perforator (SIEP) flap; superior or inferior gluteal free flap; transverse upper gracilis (TUG) flap; transverse rectus abdominis myocutaneous (TRAM) flap; d [...]
5 Active Policies
CIGNA-0398 — Transvaginal Ultrasound, Non-Obstetrical - (0398)
AETNA-CPB-0097 — External Breast Prosthesis
AETNA-CPB-0105 — Magnetic Resonance Imaging (MRI) of the Breast
AETNA-CPB-0185 — Breast Reconstructive Surgery
AETNA-CPB-0501 — Gonadotropin-Releasing Hormone Analogs and Antagonists
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.