Medical Policy Original Effective Date: Revised Date: 09/26/2018 Page 1 of 26

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1 Contents: This includes the following items: 1. Breast Reconstruction Following Mastectomy: Page 1 of Breast Implant Removal and/or Replacement and Capsulectomy: 3. Breast Reduction Mammaplasty for Symptomatic Breast Hypertrophy (Macromastia): 4. Gigantomastia of Pregnancy: 5. Gynecomastia (Surgical Treatment): 6. Tattooing: 7. External Breast Prostheses Disclaimer Definition Refer to the member s specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefit on all plans or the plan may have broader or more limited benefits than those listed in these criteria. Some procedures require prior authorization. Please check with PHP Prior Authorization Department or the PHP website. Logon to Pres Online to submit a request: Reconstructive Surgery: Reconstructive surgery is performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function but may also be done to approximate a normal or symmetric appearance. Reconstructive surgery means the following: 1. Surgery to correct a physical functional disorder resulting from a disease or congenital anomaly; following an injury or incidental to any surgery.

2 Coverage Determination Page 2 of Reconstructive surgery and associated procedures following a mastectomy that resulted from malignancy, and internal prosthesis incidental to the surgery. 3. However, surgery to correct congenital defects, developmental abnormalities, trauma, infections, tumors or disease may be covered because the surgery is considered reconstructive in nature. Cosmetic Surgery Cosmetic surgery is performed to reshape normal structures of the body to improve the patient's appearance and self-esteem is not a covered benefit. Cosmetic surgery performed purely for the purpose of enhancing one's appearance is not eligible for coverage. Additional cosmetic surgeries, done at the same time as reconstructive procedures, are not a covered benefit. Surgery will be considered cosmetic rather than reconstructive when there is no functional impairment present. However, some congenital, acquired, traumatic or developmental anomalies may not result in functional impairment; and can be considered case-by-case bases for reconstructive surgery. Treatment of complications arising from cosmetic surgery will be considered reasonable and necessary as long as infection, hemorrhage or other serious documented medical complication occurs after beneficiary has been officially discharged from the facility. 1. Breast Reconstruction Following Mastectomy: Description: Breast reconstruction after mastectomy is offered to individuals of all ages, and is an integral component of therapy for patients with cancer or who have elected to have a medically necessary prophylactic mastectomy. Breast reconstruction is a series of surgeries done following a mastectomy, either for cancer, as a prophylactic mastectomy for cancer risk, for benign disease, or accident/trauma. Breast reconstruction following mastectomy may be immediate (at the same time as the mastectomy) or delayed. The selection of various procedure reconstruction may be based on an assessment of cancer treatment, patient body habitus, smoking history, comorbidities and patient concerns. Coverage Determination:

3 Page 3 of 26 Reconstruction of the affected and the contralateral unaffected following a medically necessary mastectomy is considered a non-cosmetic procedure. Accordingly, program payment may be made for reconstruction surgery following removal of a for any medical reason. Program payment may not be made for reconstruction for cosmetic reasons Breast reconstruction following a medically necessary mastectomy is mandated coverage by the Women s Health and Cancer Rights Act of The following is an excerpt from the Act. All stages of reconstruction of the on which the mastectomy has been performed; Surgery and reconstruction of the other to produce a symmetrical appearance; and Prostheses and physical complications of all stages of mastectomy, including lymphedema. These are dependent on the manner determined in consultation with the attending physician and the patient. Coding The coding listed in this section of the medical policy is for reference only. The following CPT codes 19316, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19380, See ICD-10 listing titled ICD-10 for Reconstructive Breast Surgery: Removal of Implants. 2. Breast Implant Removal and/or Replacement and Capsulectomy: Description: Breast implant surgery can be either cosmetic or reconstructive. The two primary types of implants are salinefilled and silicone gel-filled. Breast implants may lead to complications that may necessitate removal. Common complications of implants are capsular contracture, infection, and rupture. Coverage Determination: All requests must be accompanied with the following documentation: Original indication for implant (cosmetic augmentation or reconstruction after a medically necessary mastectomy);

4 and Current symptoms; and Page 4 of 26 Imaging study demonstrating rupture (if applicable); and Photos may be required in certain circumstances (see indications below) Removal of Breast Implants Placed for Cosmetic Augmentation Breast implant removal and capsulectomy are covered for implants originally placed for cosmetic augmentation only when one of the following indications occur: Recurrent or severe infection due to implants; or Baker Class IV contracture as defined on page 5/6. or Inability to perform mammography due to severe contracture or any interference with cancer screening or evaluation; or Rupture of silicone gel-filled implants, confirmed by diagnostic studies such as mammography, CT scan, US or MRI; or If cancer is diagnosed in a patient with implants or If presence of textured implants is contributing to a cancerous or pre-cancerous conditions, such as large cell lymphoma (i.e. Castleman s Disease). No other reasons will be considered for removal of implants originally placed for cosmetic augmentation. When one of the above criteria is met, removal of the implant in the non-affected will be covered if both implants are removed at the same time. When cosmetic augmentation has been performed previously and any complications arise, excluding malignancy, coverage will not include replacement of the affected implant,

5 Page 5 of 26 replacement of the implant in the opposite, or procedures to address symmetry. Removal of Breast Implants Placed for Breast Reconstruction Breast implant removal and replacement is covered for implants placed when reconstruction has occurred for a medically necessary mastectomy, a prophylactic mastectomy for high risk of cancer, or for a congenital anomaly with one of the following indications: Recurrent or severe infection due to implants; or Baker Class III or IV contracture (see page 5/6); or Inability to perform mammography due to severe contracture or any interference with cancer screening or evaluation; or Rupture of silicon gel-filled implants, confirmed by diagnostic studies such as mammography, CT scan, US or MRI; or Rupture of saline implant (extra-capsular) if significant deformity or asymmetry is demonstrated (photographs may be required); or Removal/replacement of implant secondary to staged reconstruction post mastectomy due to cancer. When one of the above criteria is met and a unilateral implant is removed, removal and replacement of an implant in the other will be covered to maintain natural symmetry. Reconstruction or Replacement of an implant requiring removal for any of the above indications that was originally placed for reconstruction of a traumatic or surgically created deficit will be covered as medically necessary. Other exclusion: Removal of non-ruptured implants for autoimmune disease or connective tissue disease is not a covered benefit. Medical Term: Capsular contracture: The scar tissue or capsule normally

6 Page 6 of 26 forming around the implant tightens and deforms the implant. It can happen to one or both of the implanted s. Baker s Classification of Capsular Contracture: A system that assesses clinical firmness of the after implantation. Class I: The is soft with no palpable capsule, looks natural. Class II: The is a little firm with palpable capsule but looks normal. Class III: The is firm, capsule easily palpable and visually abnormal Class IV: The is hard, cold, painful and markedly distorted. Subtotal Capsulectomy: Partial removal of the thickened capsule surrounding the implant as indicated Intra- and extra-capsular rupture of implants: After implantation, a capsule is formed around the implant. If the expelled material remains within the capsule, it is an intra-capsular rupture. If the expelled material escapes the capsule, it is an extra-capsular rupture. Extra-capsular ruptures are generally identifiable on mammography, CT scan, US or MRI Coding The coding listed in this medical policy is for reference only. The following CPT codes 19316, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, See ICD-10 listing titled ICD-10 for Reconstructive Breast Surgery: Removal of Implants. See also applicable HCPCS code table. 3. Breast Reduction Mammaplasty for Symptomatic Breast Hypertrophy (Macromastia): Description: Reduction mammaplasty is a surgical procedure performed to reduce the volume and weight of the female s. A reduction mammaplasty is considered reconstructive surgery when there is a physiological impairment caused by symptomatic hypertrophy; the intent of reduction surgery is to resolve the symptoms and alleviate the physiological impairment. Cosmetic surgery performed to shape normal structures of the body in order to improve the patient s appearance and self-

7 esteem is not a covered benefit. Coverage Determination: Page 7 of 26 Presbyterian uses MCG Criteria # A-0274 (see Clinical Indication Below). Due to contractual restrictions providers may not access the MCG website but may obtain a copy of the criteria from the Prior Authorization staff. Clinical Indications Reduction mammaplasty may be indicated when ALL of the following are present: A. Breast size interferes with activities of daily living, as indicated by 1 or more of the following: Arm numbness consistent with brachial plexus compression syndrome Cervical pain Chronic pain Headaches Nipple position greater than 21 cm below suprasternal notch Persistent redness and erythema (intertrigo) below s Restriction of physical activity Severe bra strap grooving or ulceration of shoulder Shoulder pain Thoracic kyphosis Upper or lower back pain B. Surgical considerations with failure to relieve symptoms with nonsurgical treatment that includes 1 or more of the following: Four to eight visits of physical therapy or chiropractic care, and 2 to 4 months of home exercise for cervical, shoulder, or upper or lower back pain Medically supervised weight loss program for overweight or obese patient Topical and oral antifungal agents for intertrigo Trial of nonsteroidal anti-inflammatory drugs to treat pain in neck, shoulder, upper or lower back, or Wound care for skin ulceration C. Preoperative evaluation by surgeon concludes that amount of tissue to be removed (by mass or

8 Page 8 of 26 volume) will provide a reasonable expectation of symptomatic relief D. No evidence of cancer Mammoplasty: The beneficiary's medical record must contain the following information: Height and weight. Clinical evaluation of the signs or symptoms ascribed to the macromastia, therapies prior to reduction mammoplasty and the responses to these therapies. Mammogram report within preceding 18 months. The operative report with documentation of the weight of tissue removed from each, obtained in the operating room. The pathology report of the tissue removed from each. Reduction mammoplasty is performed: To reduce the size of the s and help ameliorate symptoms caused by hypertrophy. To reduce the size of a normal to bring it into symmetry with a reconstructed after cancer surgery. After full evaluation including recent mammogram (over the age 35). With histologic pathology performed on all tissue resected. Medicare medical necessity for reduction mammoplasty is limited to circumstances in which: There are signs or symptoms resulting from the enlarged s (macromastia) that have not responded adequately to non-surgical interventions. To improve or correct asymmetry following cancer surgery on one. Note: either the involved or contralateral may be treated to achieve symmetry. A reasonable and necessary reduction mammoplasty could be indicated in the presence of significantly enlarged s and the presence of at least one of the following signs or symptoms: Back pain from macromastia, unrelieved by:

9 Conservative analgesia. Page 9 of 26 Supportive measures (custom garment, etc.). Physical therapy. Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms or significant restriction of activity. Intertriginous maceration, discoloration, chronic or recurrent infection of the inframammary skin refractory to dermatologic treatment measures. Shoulder grooving to a depth greater than 1 cm with skin irritation or darkening. Graphic documentation of ptosis with nipple-areolar complex 8 cm below the inframammary crease. Surgeon's Estimate of size/weight/volume exceeds 1000 grams with the need for at least 500 gram reduction per to relieve symptoms. Coding The coding listed in this medical policy is for reference only. The applicable CPT is For ICD-10, code N62 and one of the other codes listed in table named ICD-10 for Reduction Mammoplasty. 4. Gigantomastia of Pregnancy: Description: Gestational Gigantomastia (GG) is a rare disease characterized by diffuse, extreme, and incapacitating enlargement of one or both s during pregnancy. Although benign, it can lead to a great social, emotional, and physical disability. Subtotal mastectomy or reduction mammoplasty for the unusual condition of Gigantomastia of Pregnancy is covered when accompanied by any of the following complications (and delivery is not imminent) medically appropriate: Massive infection; Significant hemorrhage; Tissue necrosis with slough; Ulceration of tissue.

10 Page 10 of 26 Coverage of reduction mammoplasty is limited to those circumstances where the medical record supports the following: The signs or symptoms have been present for at least six months. Medical treatment or physical interventions have not adequately alleviated symptoms. 5. Gynecomastia (Surgical Treatment): Description: Gynecomastia is the benign proliferation of glandular tissue in males. Surgical procedures commonly used to remove the glandular tissue include mastectomy and reduction mammaplasty. Fatty tissue alone does not meet the definition of gynecomastia. This is limited to males. For females, refer to Breast Reduction Mammaplasty for Symptomatic Breast Hypertrophy (Macromastia) Prior Authorization is required. Please check with PHP Prior Authorization Department or the PHP website. Logon to Pres Online to submit a request: Presbyterian now uses MCG Criteria # A Due to contractual restrictions providers may not access the MCG website but may obtain a copy of the criteria from the Prior Authorization staff. Mastectomy with nipple preservation or reduction mammoplasty is considered reconstructive and a covered service for males with Grade III and IV gynecomastia or abnormal development with redundancy. American Society of Plastic Surgeons gynecomastia scale: Grade II: Moderate enlargement exceeding areola boundaries with edges that are indistinct from the chest. Grade III: Moderate enlargement exceeding areola boundaries with edges that are indistinct from the chest with skin redundancy present. Grade IV: Marked enlargement with skin redundancy and feminization of the Clinical Indications for Procedure: Mastectomy for gynecomastia may be indicated for 1 or more of the following

11 Page 11 of 26 A. For prepubertal male: evaluation and treatment of underlying endocrine disorder (eg, adrenocortical tumor, congenital adrenal hyperplasia, testicular failure, Klinefelter syndrome) B. Postpubertal male and ALL of the following: Functional impairment (e.g., chronic skin irritation, pain, related psychological disorder requiring therapy) Gynecomastia did not regress after cessation of medications (e.g., calcium channel blockers, cimetidine, phenothiazines, spironolactone, theophylline) known to cause condition, or medications cannot be discontinued. Mammography or needle biopsy results show no evidence of cancer. No evidence of other medical causes for gynecomastia, as indicated by normal results for ALL of the following: o Hormone evaluation (i.e., testosterone, luteinizing hormone, follicle-stimulating hormone, estradiol, prolactin, beta-human chorionic gonadotropin) o Liver enzymes o Serum creatinine o Thyroid function tests C. Pubertal male and ALL of the following: Functional impairment (e.g., chronic skin irritation, pain, related psychological disorder requiring therapy) Gynecomastia present for 2 or more years Alternative include: Alternatives to Procedure: Radiation therapy for prostate cancer patient receiving hormonal treatment Background Gynecomastia is the benign proliferation of glandular tissue in males. The pathophysiological process of gynecomastia involves an imbalance between free estrogen and free androgen actions in the tissue, which can occur through multiple mechanisms. During mid to late puberty, more estrogen may be produced by the testes and peripheral tissues before testosterone secretion reaches adult levels, resulting in pubertal gynecomastia. Other

12 Page 12 of 26 endocrine disorders should be evaluated for and treated. Pubertal gynecomastia often resolves without treatment. In adults, gynecomastia is associated with increasing age. Causes include conditions resulting in increased serum estrogen (obesity, liver disease, hyperthyroidism), decreased testosterone synthesis (pituitary disease, congenital or acquired primary gonadal failure), androgen resistance, renal failure, and as a side effect of numerous drugs (examples: marijuana, cimetidine, anabolic steroids). A thorough history, physical exam and appropriate laboratory evaluation may reveal treatable or explanatory causes, and may include a workup for cancer. Breast biopsy is indicated when malignancy is suspected Coding The coding listed in this medical policy is for reference only. CPT and ICD-10 N62, N64.4 and codes in the N63 series group, see table titled ICD-10 for Gynecomastia (Surgical Treatment) for applicable diagnosis. 6. Tattooing: Tattooing to correct color defects of the skin may be considered reconstructive when performed in connection with a payable post-mastectomy reconstruction. Must be performed by an appropriately licensed professional Prior Authorization is required. Logon to Pres Online to submit a request at Coding The coding listed in this medical policy is for reference only. Applicable CPT for Tattoo are 11920, 11921, For diagnosis see table titled ICD-10 for Tattooing. 7. External Breast Prostheses A prosthesis is covered for a patient who has had a mastectomy, the following are HCPCS that outlines the prosthesis An external prosthesis garment, with mastectomy form (L8015) is covered for use in the postoperative period prior to a permanent prosthesis or as an alternative to a

13 mastectomy bra and prosthesis. Page 13 of 26 A mastectomy bra (L8000) is covered for a patient who has a covered mastectomy form (L8020) or silicone (or equal) prosthesis (L8030) when the pocket of the bra is used to hold the form/prosthesis. An external prosthesis of the same type can be replaced at any time if it is lost or is irreparably damaged (this does not include ordinary wear and tear). An external prosthesis of a different type can be covered at any time if there is a change in the patient's medical condition necessitating a different type of item. The Medicare program will pay for only one prosthesis per side for the useful lifetime of the prosthesis. Two prostheses, one per side, are allowed for those persons who have had bilateral mastectomies. More than one external prosthesis per side will be denied as not reasonable and necessary. Excluded: Breast prostheses, silicone or equal, with integral adhesive (L8031) have not been demonstrated to have a clinical advantage over those without the integral adhesive. Therefore, if L8031 is billed, it will be denied as not reasonable and necessary. The medical necessity for the additional features of a custom fabricated prosthesis (L8035) compared to a prefabricated silicone prosthesis has not been established, and therefore, if an L8035 prosthesis is billed, it will be denied as not reasonable and necessary. Coding The coding listed in this medical policy is for reference only. Covered and non-covered codes are within this list. Current Procedural Terminology (CPT) Codes CPT for Reconstructive Breast Surgery: Removal of Implants Following Mastectomy CPT Codes Description for Removal of Implants Following Mastectomy Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area Each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure). Q4100 Skin substitute, not otherwise specified.

14 CPT Codes Page 14 of 26 Description for Removal of Implants Following Mastectomy Replacement of tissue expander with permanent prosthesis Removal of tissue expander(s) without insertion of prosthesis Suction assisted lipectomy (for reduction of tissue); trunk Mastopexy, (Suspension of ) Mammaplasty, augmentation; without prosthetic implant Mammaplasty, augmentation; with prosthetic implant, (enlarge with implant) Removal of intact mammary implant, (removal of implant) Removal of implant material Immediate insertion of prosthesis following mastopexy, mastectomy or in reconstruction, (immediate prosthesis) Delayed insertion of prosthesis following mastopexy, mastectomy or in reconstruction, (delayed prosthesis) Nipple/areola reconstruction, ( reconstruction) Correct inverted nipple(s) Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion Breast reconstruction with latissimus dorsi flap, without prosthetic implant Breast reconstruction with free flap Breast reconstruction with other technique Breast reconstruction with transverse rectus abdominis myocutaneous flap, single pedicle, including closure of donor site Breast reconstruction with transverse rectus abdominis myocutaneous flap, single pedicle, including closure of donor site; with microvascular anastomosis Breast reconstruction with transverse rectus abdominis myocutaneous flap, double pedicle, including closure of donor site Open periprosthetic capsulotomy,, (surgery of capsule) Periprosthetic capsulectomy,, (removal of capsule) Revise reconstruction

15 CPT Codes Page 15 of 26 Description for Removal of Implants Following Mastectomy Preparation of moulage for custom implant, (design custom implant) CPT for Reduction Mammoplasty CPT Code CPT Code Description for Reduction Mammoplasty Reduction mammaplasty Suction assisted lipectomy (for reduction of tissue); trunk CPT for Gynecomastia (Surgical Treatment) CPT Code CPT Code Description for Gynecomastia Mastectomy for gynecomastia Suction assisted lipectomy (for reduction of tissue); trunk CPT for Tattooing CPT Codes CPT Code Description for Tattooing Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure), Code first HCPCS codes covered if selection criteria are met HCPCS code A4280 C1781 C1789 L8600 Q4116 HCPCS Codes Description for Covered Service Adhesive skin support attachment for use with external prosthesis, EACH Mesh (implantable) [Cortiva] Prosthesis, (implantable) Implantable prosthesis, silicone or equal Alloderm, per square centimeter

16 HCPCS code Q4122 Q4128 Q4130 S2066 S2067 S2068 L8000 L8001 L8002 L8010 L8015 L8020 L8030 L8032 L8039 L8600 Page 16 of 26 HCPCS Codes Description for Covered Service DermACELL, per sq cm Flex HD, Allopatch HD, or Matrix HD, per square centimeter Strattice TM, per sq cm Breast reconstruction with gluteal artery perforator (GAP) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a, unilateral Breast reconstruction of a single with "stacked" deep inferior epigastric perforator (DIEP) flap(s) and/ or gluteal artery perforator (GAP) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a, unilateral Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a, unilateral Breast prosthesis, mastectomy bra, without integrated prosthesis form, any size, any type **Covered for a patient who has a covered mastectomy form (L8020) or silicone (or equal) prosthesis (L8030) when the pocket of the bra is used to hold the form/prosthesis. Breast prosthesis, mastectomy bra, with integrated prosthesis form, unilateral Breast prosthesis, mastectomy bra, with integrated prosthesis form, bilateral Breast prosthesis, mastectomy sleeve Breast prosthesis external garment, with mastectomy form, post mastectomy Breast prosthesis, mastectomy form Breast prosthesis, silicone or equal, without integral adhesive Nipple prosthesis, reusable, any type, each Breast prosthesis Prosthesis, implantable, silicone/equal NON- Covered Breast Prosthesis- HCPCS

17 HCPCS Page 17 of 26 These will be denied as not reasonable and necessary. L8031 L8035 Breast prosthesis, silicone or equal, with integral adhesive Breast prosthesis custom, post mastectomy, molded to patient model ICD-10 Listings ICD-10 for Reconstructive Breast Surgery: Removal of Implants ICD-10 Reconstructive Breast Surgery- Removal of Implants C Malignant neoplasm of nipple and areola, right female C Malignant neoplasm of nipple and areola, left female C Malignant neoplasm of nipple and areola, right male C Malignant neoplasm of nipple and areola, left male C Malignant neoplasm of central portion of right female C Malignant neoplasm of central portion of left female C Malignant neoplasm of central portion of right male C Malignant neoplasm of central portion of left male C C C Malignant neoplasm of upper-inner quadrant of right female Malignant neoplasm of upper-inner quadrant of left female Malignant neoplasm of upper-inner quadrant of right male C Malignant neoplasm of upper-inner quadrant of left male C C Malignant neoplasm of lower-inner quadrant of right female Malignant neoplasm of lower-inner quadrant of left female C Malignant neoplasm of lower-inner quadrant of right male C Malignant neoplasm of lower-inner quadrant of left male C C Malignant neoplasm of upper-outer quadrant of right female Malignant neoplasm of upper-outer quadrant of left female

18 ICD-10 C Page 18 of 26 Reconstructive Breast Surgery- Removal of Implants Malignant neoplasm of upper-outer quadrant of right male C Malignant neoplasm of upper-outer quadrant of left male C C Malignant neoplasm of lower-outer quadrant of right female Malignant neoplasm of lower-outer quadrant of left female C Malignant neoplasm of lower-outer quadrant of right male C Malignant neoplasm of lower-outer quadrant of left male C Malignant neoplasm of axillary tail of right female C Malignant neoplasm of axillary tail of left female C Malignant neoplasm of axillary tail of right male C Malignant neoplasm of axillary tail of left male C Malignant neoplasm of overlapping sites of right female C Malignant neoplasm of overlapping sites of left female C Malignant neoplasm of overlapping sites of right male C Malignant neoplasm of overlapping sites of left male C Malignant neoplasm of unspecified site of right female C Malignant neoplasm of unspecified site of left female C Malignant neoplasm of unspecified site of right male C Malignant neoplasm of unspecified site of left male C79.2 Secondary malignant neoplasm of skin C79.81 Secondary malignant neoplasm of D04.5 Carcinoma in situ of skin of trunk D05.01 Lobular carcinoma in situ of right D05.02 Lobular carcinoma in situ of left D05.11 Intraductal carcinoma in situ of right D05.12 Intraductal carcinoma in situ of left

19 ICD-10 Page 19 of 26 Reconstructive Breast Surgery- Removal of Implants D05.81 Other specified type of carcinoma in situ of right D05.82 Other specified type of carcinoma in situ of left D05.91 Unspecified type of carcinoma in situ of right D05.92 Unspecified type of carcinoma in situ of left D24.1 Benign neoplasm of right D24.2 Benign neoplasm of left D24.9 Benign neoplasm of unspecified D47.Z2 Castleman disease D48.60 Neoplasm of uncertain behavior of unspecified D48.61 Neoplasm of uncertain behavior of right D48.62 Neoplasm of uncertain behavior of left D49.3 Neoplasm of unspecified behavior of N65.0 Deformity of reconstructed N65.1 Disproportion of reconstructed T85.41XA T85.41XD T85.41XS T85.42XA T85.42XD T85.42XS T85.43XA T85.43XD Mechanical complication of prosthesis and implant; Breakdown (mechanical) of prosthesis and implant, initial encounter Mechanical complication of prosthesis and implant Breakdown (mechanical) of prosthesis and implant, subsequent encounter Mechanical complication of prosthesis and implant Breakdown (mechanical) of prosthesis and implant, sequela Mechanical complication of prosthesis and implant Displacement of prosthesis and implant, initial encounter Mechanical complication of prosthesis and implant Displacement of prosthesis and implant, subsequent encounter Mechanical complication of prosthesis and implant Displacement of prosthesis and implant, sequela Mechanical complication of prosthesis and implant; Leakage of prosthesis and implant, initial encounter Mechanical complication of prosthesis and implant Leakage of prosthesis and implant, subsequent

20 ICD-10 T85.43XS T85.44XA T85.44XD T85.44XS T85.49XA T85.49XD T85.49XS T85.79XA T85.79XD T85.79XS Z44.31 Z44.32 Page 20 of 26 Reconstructive Breast Surgery- Removal of Implants encounter Mechanical complication of prosthesis and implant Leakage of prosthesis and implant, sequela Mechanical complication of prosthesis and implant Capsular contracture of implant, initial encounter Mechanical complication of prosthesis and implant Capsular contracture of implant, subsequent encounter Mechanical complication of prosthesis and implant Capsular contracture of implant, sequela Mechanical complication of prosthesis and implant Other mechanical complication of prosthesis and implant, initial encounter Mechanical complication of prosthesis and implant Other mechanical complication of prosthesis and implant, subsequent encounter Mechanical complication of prosthesis and implant Other mechanical complication of prosthesis and implant, sequela Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, subsequent encounter Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, sequela Encounter for fitting and adjustment of external right prosthesis Encounter for fitting and adjustment of external left prosthesis Z Encounter for adjustment or removal of right implant Z Encounter for adjustment or removal of left implant Z Encounter for adjustment or removal of unspecified implant Z48.3 Aftercare following surgery for neoplasm Z85.3 Personal history of malignant neoplasm of Z98.82 Breast implant status ICD-10 for Reduction Mammoplasty when using CPT 19318

21 Page 21 of 26 ICD-10 CODE ICD-10 Description for Reduction Mammoplasty (when using CPT 19318) L26 Exfoliative dermatitis L30.4 Erythema intertrigo L54 Erythema in diseases classified elsewhere L95.1 Erythema elevatum diutinum L98.2 Febrile neutrophilic dermatosis [Sweet] M Pain in right shoulder M Pain in left shoulder M54.2 Cervicalgia M54.6 Pain in thoracic spine M54.9 Dorsalgia, unspecified N62 Hypertrophy of N64.1 Fat necrosis of N64.81 Ptosis of N65.1 Disproportion of reconstructed O Nonpurulent mastitis associated with pregnancy, first trimester O Nonpurulent mastitis associated with pregnancy, second trimester O Nonpurulent mastitis associated with pregnancy, third trimester R21 Rash and other nonspecific skin eruption Z48.3* Aftercare following surgery for neoplasm *Note: Use Z48.3 to indicate a mammoplasty to reduce the size of a normal to bring it into symmetry with a reconstructed after cancer surgery. When reporting Z48.3 it is not necessary to report N62. ICD-10 for Gynecomastia (Surgical Treatment) when using CPT ICD-10 Codes N62 ICD-10 Code Description for Gynecomastia Surgical Treatment (for use with CPT 19300) Hypertrophy of N64.4 Mastodynia N63 Unspecified lump in (Nodule(s) NOS in ) N63.0 Unspecified lump in unspecified N63.1 Unspecified lump in the right N63.10 Unspecified lump in the right, unspecified quadrant

22 ICD-10 Codes Page 22 of 26 ICD-10 Code Description for Gynecomastia Surgical Treatment (for use with CPT 19300) N63.11 Unspecified lump in the right, upper outer quadrant N63.12 Unspecified lump in the right, upper inner quadrant N63.13 Unspecified lump in the right, lower outer quadrant N63.14 Unspecified lump in the right, lower inner quadrant N63.2 Unspecified lump in the left N63.20 Unspecified lump in the left, unspecified quadrant N63.21 Unspecified lump in the left, upper outer quadrant N63.22 Unspecified lump in the left, upper inner quadrant N63.23 Unspecified lump in the left, lower outer quadrant N63.24 Unspecified lump in the left, lower inner quadrant N63.3 Unspecified lump in axillary tail N63.31 Unspecified lump in axillary tail of the right N63.32 Unspecified lump in axillary tail of the left N63.4 Unspecified lump in, subareolar N63.41 Unspecified lump in right, subareolar N63.42 Unspecified lump in left, subareolar ICD-10 for Tattooing ICD-10 Codes ICD-10 Codes Description for Tattooing L81.8 Other specified disorders of pigmentation L81.9 Disorder of pigmentation, unspecified ICD-10 for External Breast Prostheses ICD-10 Codes ICD-10 Codes Description for External Breast Prostheses C Malignant neoplasm of nipple and areola, right female

23 ICD-10 Codes Page 23 of 26 ICD-10 Codes Description for External Breast Prostheses C Malignant neoplasm of nipple and areola, left female C Malignant neoplasm of nipple and areola, unspecified female C Malignant neoplasm of central portion of right female C Malignant neoplasm of central portion of left female C C C C C C C C C C C C C Malignant neoplasm of central portion of unspecified female Malignant neoplasm of upper-inner quadrant of right female Malignant neoplasm of upper-inner quadrant of left female Malignant neoplasm of upper-inner quadrant of unspecified female Malignant neoplasm of lower-inner quadrant of right female Malignant neoplasm of lower-inner quadrant of left female Malignant neoplasm of lower-inner quadrant of unspecified female Malignant neoplasm of upper-outer quadrant of right female Malignant neoplasm of upper-outer quadrant of left female Malignant neoplasm of upper-outer quadrant of unspecified female Malignant neoplasm of lower-outer quadrant of right female Malignant neoplasm of lower-outer quadrant of left female Malignant neoplasm of lower-outer quadrant of unspecified female C Malignant neoplasm of axillary tail of right female C Malignant neoplasm of axillary tail of left female C Malignant neoplasm of axillary tail of unspecified female C Malignant neoplasm of overlapping sites of right female C Malignant neoplasm of overlapping sites of left female C Malignant neoplasm of overlapping sites of unspecified female

24 ICD-10 Codes Page 24 of 26 ICD-10 Codes Description for External Breast Prostheses C Malignant neoplasm of unspecified site of right female C Malignant neoplasm of unspecified site of left female C Malignant neoplasm of unspecified site of unspecified female C79.81 Secondary malignant neoplasm of D05.00 Lobular carcinoma in situ of unspecified D05.01 Lobular carcinoma in situ of right D05.02 Lobular carcinoma in situ of left D05.10 Intraductal carcinoma in situ of unspecified D05.11 Intraductal carcinoma in situ of right D05.12 Intraductal carcinoma in situ of left D05.80 Other specified type of carcinoma in situ of unspecified D05.81 Other specified type of carcinoma in situ of right D05.82 Other specified type of carcinoma in situ of left D05.90 Unspecified type of carcinoma in situ of unspecified D05.91 Unspecified type of carcinoma in situ of right D05.92 Unspecified type of carcinoma in situ of left I97.2 Postmastectomy lymphedema syndrome Z85.3 Personal history of malignant neoplasm of Z90.10 Acquired absence of unspecified and nipple Z90.11 Acquired absence of right and nipple Z90.12 Acquired absence of left and nipple Z90.13 Acquired absence of bilateral s and nipples References 1. NCCN Clinical Practice Guidelines in Oncology, (NCCN Guidelines), Breast Cancer, Version March 20, Accessed 08/08/ Centers for Medicare and Medicaid Services. The

25 Page 25 of 26 Women s Health and Cancer Rights Act. Title IX, Sec. 173 (3). Required Coverage for Reconstructive Surgery Following Mastectomy. Accessed 08/08/ CMS, NCD for Breast Reconstruction Following Mastectomy-140.2, effective date 01/01/1997. Accessed 09/13/ CMS, Cosmetic and Reconstructive Surgery LCD-(L35090), Revision Effective 04/14/2017. (Note: Original LCD L32763). Revision History Number R4, See Section: 3 Reconstructive Breast Surgery: Removal of Breast Implants. Accessed 08/08/ CGS, DME MAC J-C, LCD (L33317), Revision History Number 4, External Breast Prostheses, Revision Effective Date: 01/01/2017, Accessed 09/13/ CGS, DME Standard Documentation Requirements for all Claims Submitted to DME MACs (A55426) 7. US Food and Drug Administration, Medical Devices, Risks of Breast Implants, Capsular Contracture, last updated 04/06/2018. Accessed 08/08/ MCG, ACG: A-0274, Reduction Mammaplasty (Mammoplasty), 21 st Edition. Last Update 02/02/2017. Accessed 08/08/ MCG, ACG: A-0273, Mastectomy for Gynecomastia, 21 st Edition, Last Update 02/02/2017. Accessed 08/08/ Aetna, Breast Reconstructive Surgery, Number 0185, Last Review: 07/31/2018, Next Review: 02/14/2019. Accessed 08/10/2019. Approval Signatures Clinical Quality Committee: Thomas Rothfeld MD Medical Directory: Norman White MD Approval Dates September 26, 2018 Publications History 09/26/18 Combined previous MPM s into this Policy. MPM 2.2, Breast Implant Removal or Replacement & Capsulectomy MPM 2.5, Breast Reduction Mammoplasty MPM 2.11, Breast Reconstruction Following Mastectomy MPM 7.0, Gynecomastia

26 Page 26 of 26 This is intended to represent clinical guidelines describing medical appropriateness and is developed to assist Presbyterian Health Plan and Presbyterian Insurance Company, Inc. (Presbyterian) Health Services staff and Presbyterian medical directors in determination of coverage. The is not a treatment guide and should not be used as such. For those instances where a member does not meet the criteria described in these guidelines, additional information supporting medical necessity is welcome and may be utilized by the medical director in reviewing the case. Please note that all Presbyterian Medical Policies are available online at: Click here for Medical Polices