Breast Surgery Corporate Medical Policy

Transcription

1 File name: Breast Surgery File cde: UM.SURG.17 Originatin: 2016 Last Review: 07/2018 (PA list review) Next Review: 08/2019 Effective Date: 08/01/2018 Breast Surgery Crprate Medical Plicy Descriptin/Summary This plicy fcuses n breast-related prcedures that include mastectmy fr cancer, prphylactic mastectmy, recnstructin, the management f breast implants, breast reductins, crrectins fr certain asymmetries. BCBVT cvers medically necessary prcedures related t physilgical dysfunctin, such as breast cancer, cngenital and develpmental disrders, infectin, trauma, surgical cmplicatins and macrmastia causing physilgical dysfunctin in men and wmen. BCBSVT cnsiders prcedures that are nly perfrmed t reshape nrmal structures f the bdy in rder t imprve ne s appearance r self-esteem nly, t be csmetic and therefre nn-cvered as benefit exclusins. Plicy Cding Infrmatin Click the links belw fr attachments, cding tables & instructins. Attachment I CPT / Cding Table Requests fr breast surgery shuld be accmpanied by the fllwing dcumentatin: The name and date f the prpsed surgery. Date f accident r injury, if applicable Histry f present illness and/r cnditins including diagnses Dcumentatin f diagnsis, functinal impairment, pain r significant anatmic variance Hw the treatment can be reasnably expected t imprve the functinal impairment If applicable, the descriptin f and CPT cding fr planned staged prcedure fllwing acute repair, within tw years f previus stage r initial primary repair Any additinal infrmatin listed fr a specific prcedure as indicated fr the specific prcedures listed belw. BCBSVT will review prcedures intended t crrect cmplicatins frm a csmetic prcedure, whether the riginal prcedure was medically necessary r a nn-cvered service. In rder Page 1 f 12

2 fr these crrectins t be cnsidered medically necessary the subsequent surgery needs t be recnstructive in nature (i.e. prcedures perfrmed n abnrmal structures f the bdy, caused by cngenital defects, develpmental abnrmalities, trauma, infectin, tumrs r disease. It is generally perfrmed t imprve functin, but may als be dne t apprximate nrmal appearance). The prcedures in this medical plicy are cnsidered medically necessary in accrdance with the Wmen s Health and Cancer Rights Act f 1998, when perfrmed as a breast recnstructin prcedure fllwing r in cnnectin with mastectmy, breast cnservatin therapy (BCT) r ther diagnstic prcedures causing defrmity f the breast, in cnnectin with breast cancer, evaluatin f breast cancer r suspected breast cancer, t prevent develpment f breast cancer in high risk patients, recnstructin fllwing breast tissue destructin due t accidental injury, trauma, infectin r disease (including ther cancers). If the intended service relates t gender reassignment services, please refer t the BCBSVT Transgender Services medical plicy. Plicy and Guidelines Breast Prsthetics ( cdes L2999, L3999, L5999, L7499, *L8020, *L8030, *L8031, L8039, L8499, L8699) We cnsider the prcedure medically necessary fr the fllwing indicatins: - A r a histry f breast cancer - Fllwing a mastectmy fr cancer - Fllwing a prphylactic mastectmy - Fr absence f the breast due t trauma, disease r infectin - A diagnsis f Pland s syndrme We cnsider the prcedure csmetic and therefre nt cvered as a benefit exclusin when: - Nne f the abve indicatins are met. - Obtained nly t imprve appearance r t imprve ne s self-esteem. *When billed with a prir apprval is nt required. Mastectmy fr Gynecmastia (CPT cde 19300) - surgery due t develpment f abnrmally large mammary gland in bilgically male individuals. We cnsider the prcedure medical necessary fr the fllwing: - With a ; OR - If the criteria fr a Prphylactic Mastectmy are met. - When all f the fllwing are met: Dcumented symptms, including pain r tenderness directly related t the breast tissue, and which has a clinically significant impact upn nrmal activities f daily living despite nn-narctic analgesics and anti-inflammatry agents; AND Apprpriate diagnstic evaluatin has been dne fr pssible underlying etilgy; AND Page 2 f 12

3 The tissue remved must be glandular breast tissue; and The extra tissue must nt be the result f besity, adlescence, r reversible effects f drug treatment that can be discntinued. (This includes drug-induced Gynecmastia remaining unreslved six mnths after cessatin f the causative drug therapy; Additinally, fr thse under 18 years f age, ne f the fllwing must be submitted as evidence f puberty cmpletin.* * Evidence f puberty cmpletin: Dcumented tanner stage IV r V fr members aged 15-18, AND Stable height measurements fr 6 mnths, OR Puberty cmpletin as shwn n wrist radigraph. We cnsider the prcedure nt medically necessary when any f the fllwing is present: - Cnservative attempts t cntrl the pain r tenderness, such as nn- narctic analgesics and anti-inflammatry agents, have nt been attempted. - Use f a medicatin knwn t cause gynecmastia has nt been discntinued. - The apprpriate diagnstic evaluatin fr etilgy has nt been cmpleted. We cnsider the prcedure csmetic and therefre nt cvered as a benefit exclusin fr the fllwing circumstances (nt an all-inclusive list): - The tissue being remved is nt glandular in nature; OR - The medically necessary criteria abve is nt met and the prcedure is intended nly t imprve appearance r t imprve ne s emtinal well-being. Prphylactic Mastectmy (CPT cdes 19303, 19304) Surgical remval f breasts due t a high cancer risk. It is strngly recmmended that all candidates fr prphylactic mastectmy underg cunseling regarding cancer risks frm a health prfessinal skilled in assessing cancer risk ther than the perating surgen and discussin f the varius treatment ptins, including increased surveillance r chempreventin with the apprpriate medicatin e.g. tamxifen r ralxifene. Patients with a high risk f breast cancer may be defined as ne r mre f the fllwing: a knwn BRCA1 r BRCA2 mutatin r at high risk f BRCA1 r BRCA2 mutatin due t a knwn presence f the mutatin in relatives r anther gene mutatin assciated with increased risk (eg, PTEN, TP53, CDH1, and STK11) r Li-Fraumeni syndrme r Cwden syndrme r Bannayan-Riley-Ruvalcaba syndrme r a first-degree relative with ne f these syndrmes r high risk (lifetime risk abut 20% t 25% r greater) f develping breast cancer as identified by mdels that are largely defined by family histry r received raditherapy t the chest between 10 and 30 years f age We cnsider the prcedure medically necessary fr any f the fllwing: - In patients at high risk f breast cancer as defined abve. - In patients with inflammatry breast cancer. Page 3 f 12

4 - In patients with lbular carcinma in situ. - In patients with such extensive mammgraphic abnrmalities (i.e. calcificatins) that adequate bipsy r excisin is impssible. We cnsider the prcedure investigatinal fr all ther indicatins, including, but nt limited t cntralateral prphylactic mastectmy in wmen with breast cancer wh d nt meet the high risk criteria as defined abve. Breast Recnstructin (CPT cdes 15777,19340*, 19342*, 19350*, 19357*, 19361*, 19364*, 19366*, 19367*, 19368*, 19369*, 19380*). Utilizatin f natural r artificial tissue t recnstruct breasts fllwing mastectmy, breast cnservatin therapy, burns, trauma and diagnstic defrmity We cnsider recnstructin medically necessary fr any f the fllwing: - Fr the affected breast When breast tissue is affected by disease, trauma, burns r infectin When perfrmed in cnnectin with cancer, the evaluatin f cancer, the evaluatin f suspected cancer (i.e. fllwing bipsy r lumpectmy), r the preventin f breast cancer develpment in high risk patients; OR Fr prstheses and physical cmplicatins* f all stages f mastectmy, breast cnservatin therapy (BCT) r ther diagnstic prcedures causing defrmity (i.e. fllwing bipsy r lumpectmy) including lymphedema treatment. *Physical cmplicatins f a staged mastectmy may include, but is nt limited t, abdminal scar revisin/release related t prir tissue needed fr breast recnstructin. Fllwing the remval f a ruptured silicne gel-filled implant Fr the unaffected breast in rder t create a symmetrical appearance *When billed with a, fllwing an apprved mastectmy, prir apprval is nt required. We cnsider the fllwing csmetic and therefre nt cvered as a benefit exclusin: Breast recnstructin fllwing mastectmy fr gynecmastia. Ntes: Breast recnstructin utilizing autlgus fat grafting t the breast with adipse-derived stem cells is cnsidered investigatinal. CPT cde shuld represent autlgus fat grafting frm direct harvest and is apprpriate. Allgraft material fr use in breast recnstructive therapy ( Q4100, Q4107, Q4116, Q4128) Implant repsitining Inverted nipple crrectin- (CPT 19355) Mastpexy (CPT 19316) If the preceding criteria fr Breast Recnstructin are nt met, the fllwing prcedures are cnsidered csmetic and therefre nt cvered as a benefit exclusin: Mastpexy (CPT 19316) Page 4 f 12

5 Inverted nipple crrectin (CPT 19355) Implant repsitining Tatting f the nipple and/r arela (CPT 11920, 11921, 11922) Reductin Mammplasty (CPT cde 19318) Surgical reductin f breasts in wmen due t size and persistent symptms. We cnsider the prcedure medically necessary fr the treatment f macrmastia fr the fllwing: - Breast size is stable fr six t twelve mnths prir t surgery. AND - A minimum f 6-weeks f tw persistent well-dcumented symptms which impair functin such as shulder, neck, r back pain r pain interfering with sleep related t macrmastia that is nt respnsive t cnservative therapy, such as an apprpriate supprt bra, exercises, heat/cld treatment, and apprpriate nnsteridal anti-inflammatry agents/muscle relaxants OR - One f the abve symptms AND recurrent r chrnic intertrig between the pendulus breast and the chest wall that is resistant t tpical treatment. - Additinally, fr thse under 18 years f age, ne f the fllwing must be submitted as evidence f puberty cmpletin.* * Evidence f puberty cmpletin: Dcumented tanner stage IV r V fr members aged 15-18, AND Stable height measurements fr 6 mnths, OR Puberty cmpletin as shwn n wrist radigraph. Breast Reductin (Reductin Mammaplasty CPT 19318) is cnsidered medically necessary when in cnnectin with breast recnstructin fllwing a mastectmy. - We cnsider reductin mammplasty csmetic and therefre nt cvered as a benefit exclusin fr any f the fllwing: Perfrmed in rder t imprve athletic perfrmance OR Obtained nly t imprve appearance r t imprve ne s self-esteem - We cnsider the prcedure investigatinal fr all ther indicatins nt utlined abve. Remval f implant(s) (CPT cdes 19328, 19330); insertin f implant(s) (CPT cdes 19340, 19342, C1789); Periprsthetic capsultmy r capsulectmy (CPT cdes 19370, 19371): the remval and replacement f breast implants riginally placed fllwing mastectmy. - Additinal Dcumentatin Required: Date f implantatin and type f implant Objective evidence f leakage Baker Cntracture Class* - We cnsider the prcedure medically necessary fr the any f the fllwing: Page 5 f 12

6 Explantatin (remval f implant) f a silicne gel-filled r saline filled implant with a dcumented implant rupture, extrusin, Baker Class IV* cntracture, rsurgical treatment f cancer r ther disease, infectin, trauma r burn. - We cnsider the prcedures nt medically necessary fr the any f the fllwing: Explantatin f a when the riginal recnstructin was fr csmetic reasns and the medically necessary criteria abve is nt met. Systemic symptms, attributed t cnnective tissue diseases, autimmune diseases, etc.; Baker class III cntractures in patients with implants fr csmetic purpses; Rupture f a saline implant in patients with implants fr csmetic purpses; Pain nt related t cntractures r rupture. - We cnsider the prcedure csmetic and therefre nt cvered as a benefit exclusin fr the fllwing: Obtained nly t imprve appearance r t imprve ne s self-esteem. Grade I: Grade II: Grade III: Grade IV: *Baker Classificatin f breast cntractures: Augmented breast feels as sft as a nrmal breast Breast is less sft and the implant can be palpated but is nt visible. Breast is firm, palpable and the implant (r its distrtin) is visible Breast is hard, painful, cld, tender and distrted Unilateral Breast Surgery fr Asymmetry reductin mammplasty (CPT cde 19318) and/r augmentatin mammplasty (CPT cde & 19325) - surgical recnstructin in females f ne breast by either reducing r enlarging. - Additinal dcumentatin Required: Histry and physical findings Height and weight Size f each breast Date f previus surgery, if applicable Pathlgic diagnsis, if applicable Estimate f amunt f tissue t be remved in a reductin r size f implant fr augmentatin. Additinally, fr thse under 18 years f age, ne f the fllwing must be submitted as evidence f puberty cmpletin.* * Evidence f puberty cmpletin: Dcumented tanner stage IV r V fr members aged 15-18, AND Stable height measurements fr 6 mnths, OR Puberty cmpletin as shwn n wrist radigraph. Page 6 f 12

7 - We cnsider the prcedures medically necessary fr any f the fllwing indicatins: Bilgical females must be at least 15 years f age and have reached puberty*, and have a diagnsis f Pland s syndrme (cngenital absence f breasts) OR A disfiguring traumatic accident (e.g. burn) r cmplicatin f medical treatment (e.g. necrsis) OR A breast infectin resulting in disfigurement - We cnsider prcedures fr the fllwing csmetic and therefre nt cvered as a benefit exclusin: Unilateral augmentatin r reductin mammplasty intended t create symmetry between therwise nrmal breasts and the medically necessary criteria abve is nt met OR Unilateral augmentatin r reductin mammplasty intended nly t imprve appearance r t imprve a ne s self-esteem Reference Resurces 1. Blue Crss and Blue Shield Assciatin. Medical Plicy Reference Manual # Surgical Treatment f Bilateral Gynecmastia, last reviewed: February Blue Crss and Blue Shield Assciatin. Medical Plicy Reference Manual # Adipse-Derived Stem Cells in Autlgus Fat Grafting t the Breast, last reviewed: Octber Blue Crss and Blue Shield Assciatin. Medical Plicy Reference Manual # Prphylactic Mastectmy, last reviewed: February Cuhaci, N., Plat, S.B., Evrans, B., Esry, R. and Cakir, B. Gynecmastia: clinical evaluatin and management. Indian Jurnal f Endcrinlgy and Metablism Mar- Apr; 18(2): Kerrigan, C.L., Cllins, E.D., Kim, H.M., Schnurr, P.L., Cunningham, B. and Lwery, J. Reductin mammplasty: defining medical necessity. Medical Decisin Making May- Jun; 22(3): Wlfswinkel, B.S., Lemaine, V., Weathers, W. M., Chike-Obi, C.J, Xue, A.S. and Heller, L. Hyperplastic Breast Anmalies in the Female Adlescent Breast. Seminars in Plastic Surgery Feb; Related Plicies BCBSVT Medical Plicy n Transgender Services BCBSVT Medical Plicy n Biengineered Skin and Sft Tissue Substitutes Dcument Precedence Blue Crss and Blue Shield f Vermnt (BCBSVT) Medical Plicies are develped t prvide clinical guidance and are based n research f current medical literature and review f cmmn medical practices in the treatment and diagnsis f disease. The applicable grup/individual cntract and member certificate language, r emplyer s benefit plan if an ASO grup, determines benefits that are in effect at the time f service. Since medical practices and knwledge are cnstantly evlving, BCBSVT reserves the right t review and Page 7 f 12

8 revise its medical plicies peridically. T the extent that there may be any cnflict between medical plicy and cntract/emplyer benefit plan language, the member s cntract/emplyer benefit plan language takes precedence Audit Infrmatin BCBSVT reserves the right t cnduct audits n any prvider and/r facility t ensure cmpliance with the guidelines stated in the medical plicy. If an audit identifies instances f nn-cmpliance with this medical plicy, BCBSVT reserves the right t recup all nncmpliant payments. Benefit Determinatin Guidance Administrative and Cntractual Guidance Prir apprval is required and benefits are subject t all terms, limitatins and cnditins f the subscriber cntract. Incmplete authrizatin requests may result in a delay f decisin pending submissin f missing infrmatin. T be cnsidered cmpete, see plicy guidelines abve. An apprved referral authrizatin fr members f the New England Health Plan (NEHP) is required. A prir apprval fr Access Blue New England (ABNE) members is required. NEHP/ABNE members may have different benefits fr services listed in this plicy. T cnfirm benefits, please cntact the custmer service department at the member s health plan. Federal Emplyee Prgram (FEP): Members may have different benefits that apply. Fr further infrmatin please cntact FEP custmer service r refer t the FEP Service Benefit Plan Brchure. It is imprtant t verify the member s benefits prir t prviding the service t determine if benefits are available r if there is a specific exclusin in the member s benefit. Cverage varies accrding t the member s grup r individual cntract. Nt all grups are required t fllw the Vermnt legislative mandates. Member Cntract language takes precedence ver medical plicy when there is a cnflict. If the member receives benefits thrugh an Administrative Services Only (ASO) grup, benefits may vary r nt apply. T verify benefit infrmatin, please refer t the member s emplyer benefit plan dcuments r cntact the custmer service department. Language in the emplyer benefit plan dcuments takes precedence ver medical plicy when there is a cnflict. Plicy Implementatin/Update infrmatin 08/2016 New plicy. 12/2016 Added CPT Cde fr clarificatin in medical plicy. Page 8 f 12

9 08/2017 Reviewed and vted at HPC 08/07/2017 with the fllwing: Updated related plicies sectin, remved language under prphylactic mastectmy sectin, added CPT cde as medically necessary, remved language under breast recnstructin added additinal medical criteria under breast recnstructin, added cding table t align with cdes cntained within the medical plicy, remved language under remval f implants, remved language under unilateral breast surgery fr asymmetry. 07/2018 Added CPT cde t require PA Eligible prviders Qualified healthcare prfessinals practicing within the scpe f their license(s). Apprved by BCBSVT Medical Directrs Date Apprved Gabrielle Bercy-Rbersn, MD, MPH, MBA Senir Medical Directr Chair, Health Plicy Cmmittee Jshua Plavin, MD, MPH, MBA Chief Medical Officer Attachment I CPT / Cding Table Cde Type Number Brief Descriptin Plicy Instructins The fllwing cdes will be cnsidered as medically necessary when applicable criteria have been met. Tatting, intradermal intrductin f insluble paque pigments t crrect clr defects f skin, including micrpigmentatin; 6.0 sq cm r CPT less CPT Tatting, intradermal intrductin f insluble paque pigments t crrect clr defects f skin, including micrpigmentatin; 6.1 t 20.0 sq cm Page 9 f 12

10 CPT CPT Tatting, intradermal intrductin f insluble paque pigments t crrect clr defects f skin, including micrpigmentatin; each additinal 20.0 sq cm, r part theref (List separately in additin t cde fr primary prcedure) Implantatin f bilgic implant (eg, acellular dermal matrix) fr sft tissue reinfrcement (ie, breast, trunk)(list separately in additin t cde fr primary prcedure) CPT Mastectmy fr gynecmastia CPT Mastectmy, partial (eg, lumpectmy, tylectmy, quadrantectmy, segmentectmy) CPT Mastectmy, partial (eg, lumpectmy, tylectmy, quadrantectmy, segmentectmy); with axillary lymphadenectmy CPT Mastectmy, simple, cmplete CPT Mastectmy, subcutaneus CPT Mastpexy CPT Reductin mammaplasty CPT Mammaplasty, augmentatin; withut prsthetic implant CPT Mammaplasty, augmentatin; with prsthetic implant CPT Remval f intact mammary implant CPT Remval f mammary implant material CPT Immediate insertin f breast prsthesis fllwing mastpexy, mastectmy r in recnstructin Page 10 f 12

11 CPT Delayed insertin f breast prsthesis fllwing mastpexy, mastectmy r in recnstructin CPT Nipple/arela recnstructin CPT Crrectin f inverted nipples CPT Breast recnstructin, immediate r delayed, with tissue expander, including subsequent expansin CPT CPT CPT CPT CPT CPT CPT CPT Breast recnstructin with latissimus drsi flap, withut prsthetic implant Breast recnstructin with free flap Breast recnstructin with ther technique Breast recnstructin with transverse rectus abdminis mycutaneus flap (TRAM), single pedicle, including clsure f dnr site Breast recnstructin with transverse rectus abdminis mycutaneus flap (TRAM), single pedicle, including clsure f dnr site; with micrvascular anastmsis (supercharging) Breast recnstructin with transverse rectus abdminis mycutaneus flap (TRAM), duble pedicle, including clsure f dnr site Open periprsthetic capsultmy, breast Preprsthetic capsulectmy, breast CPT Revisin f recnstructed breast CPT CPT Preparatin f mulage fr custm breast implant Tissue grafts, ther (eg, paratenn, fat, dermis) Page 11 f 12

12 L8020 L8030 L8031 L8039 L8499 L8699 Q4100 Q4107 Breast prsthesis, mastectmy frm Breast prsthesis, silicne r equal, withut integral adhesive Breast prsthesis, silicne r equal with integral adhesive Breast prsthesis, nt therwise specified Unlisted prcedure fr miscellaneus prsthetic services Prsthetic implant, nt therwise specified Skin substitute, nt therwise specified Graftjacket, per square centimeter Q4116 Allderm, per square centimeter Q4128 S2066 S2067 S2068 FlexHD, Allpatch HD, r Matrix HD, per square centimeter Breast recnstructin with gluteal artery perfratr (GAP) flap, including harvesting f the flap, micrvascular transfer, clsure f dnr site and shaping the flap int a breast, unilateral Breast recnstructin f a single breast with stacked deep inferir epigastric perfratr (DIEP) flap(s) and/r gluteal artery perfratr (GAP) flap(s), including harvesting f the flap(s), micrvascular transfer, clsure f dnr site(s) and shaping the flap int a breast, unilateral Breast recnstructin with deep inferir epigastric perfratr (DIEP) flap, r superficial inferir epigastric artery (SIEA) flap, including harvesting f the flap, micrvascular transfer, clsure f dnr site and shaping the flap int a breast, unilateral Page 12 f 12