Breast Reconstruction - Medicare Advantage

This policy addresses breast reconstruction services — including autologous flap and implant-based reconstruction, tissue expanders, capsulotomy/capsulectomy, and related intraoperative monitoring (e.g., near‑infrared spectroscopy) — to rebuild breast shape after mastectomy, repair deformity from a medically necessary lumpectomy, or treat trauma (and to manage implant‑related complications such as BIA‑ALCL). Coverage and specific requirements, exclusions for purely cosmetic procedures, and technique- or device-specific rules are determined by applicable CMS national/local coverage determinations and the Medicare Administrative Contractor (MAC) LCDs for the patient’s jurisdiction.

"No explicit covered indications are listed in this excerpt. Coverage determinations are delegated to the applicable MAC LCDs and CMS NCDs/LCAs."

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