Axillary Reverse Mapping for Prevention of Breast Cancer-Related Lymphedema

This policy addresses axillary reverse mapping (reverse lymphatic mapping) performed during breast cancer surgery to identify and spare axillary lymph nodes/lymphatics to potentially reduce breast cancer–related lymphedema in patients undergoing axillary procedures or axillary-directed radiotherapy, notably those having SLNB or ALND and breast cancer survivors at higher risk (e.g., ALND, multiple positive nodes, elevated BMI). Applicability is limited to specified fully insured plans in Illinois (individual/family, student, fully insured small/mid/large group, HMO/EPO/PPO/POS and Medicaid when the policy is amended/delivered/issued/renewed on or after 2025‑01‑01), and ARM is considered experimental/investigational/unproven with insufficient high‑quality evidence for routine use, is adjunctive to surgery, and generally does not apply to ASO groups.

"Medically necessary reconstructive services intended to restore physical appearance of body structures damaged by trauma."