Breast Reconstruction Post Mastectomy - Oxford Health Care

CLINICAL POLICY

BREAST RECONSTRUCTION
POST MASTECTOMY

Policy Number: SURGERY 095.11 T2
Effective Date: January 1, 2016

Table of Contents Page Related Policies:
Refer to the Background
CONDITIONS OF COVERAGE................................... 1 section below for a list of
BENEFIT CONSIDERATIONS.................................... 2 related policies
COVERAGE RATIONALE........................................... 2
DEFINITIONS.............................................................. 4
APPLICABLE CODES…............................................. 5
BACKGROUND........................................................... 9
REFERENCES............................................................ 9
POLICY HISTORY/REVISION INFORMATION........... 10

The services described in Oxford policies are subject to the terms, conditions and limitations of
the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to
Medicare Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies
as necessary without prior written notice unless otherwise required by Oxford's administrative
procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of
its subsidiaries as appropriate for these policies.

Certain policies may not be applicable to Self-Funded Members and certain insured products.

Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage

is provided or if there are any exclusions or benefit limitations applicable to any of these policies.
If there is a difference between any policy and the Member’s plan of benefits or Certificate of

Coverage, the plan of benefits or Certificate of Coverage will govern.

CONDITIONS OF COVERAGE

Applicable Lines of This policy applies to Oxford Commercial plan membership
Business/Products General benefits package
No
Benefit Type
Yes1,2
Referral Required
Yes1
(Does not apply to non-gatekeeper Inpatient, Office, Outpatient
products)
1Medical Director review is not required for reconstructive
Authorization Required procedures following a mastectomy for breast cancer (or

(Precertification always required for
inpatient admission)

Precertification with Medical
Director Review Required

Applicable Site(s) of Service

(If site of service is not listed, Medical
Director review is required)

Special Considerations

Breast Reconstruction Post Mastectomy: Clinical Policy (Effective 01/01/2016) 1
©1996-2016, Oxford Health Plans, LLC

Special Considerations prophylaxis)

(continued) 2Precertification is required for services covered under the
Member's General Benefits package when performed in the
office of a participating provider. For Commercial plans,
precertification is not required, but is encouraged for out-of-
network services performed in the office that are covered
under the Member's General Benefits package. If
precertification is not obtained, Oxford may review for
medical necessity after the service is rendered.

BENEFIT CONSIDERATIONS

Before using this guideline, please check the Member specific benefit document and any federal
or state mandates, if applicable.

Essential Health Benefits for Individual and Small Group:
For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA)
requires fully insured non-grandfathered individual and small group plans (inside and outside of
Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large
group plans (both self-funded and fully insured), and small group ASO plans, are not subject to
the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage
for benefits which are deemed EHBs (such as maternity benefits), the ACA requires all dollar
limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The
determination of which benefits constitute EHBs is made on a state by state basis. As such,
when using this guideline, it is important to refer to the member specific benefit document to
determine benefit coverage.

COVERAGE RATIONALE

Indications for Coverage

Breast reconstruction is covered for Members who have a mastectomy with or without a
diagnosis of cancer. Mastectomy includes partial (lumpectomy, tylectomy, quadrantectomy,
and segmentectomy), simple, and radical. This benefit does not include aspirations, biopsy
(open or core), excision of cysts, fibroadenomas or other benign or malignant tumors, aberrant
breast tissue, duct lesions, nipple or areolar lesions, or treatment of gynecomastia.

There is not a time frame in which the Member is required to have the reconstruction done
post mastectomy under the Women’s Health and Cancer Rights Act of 1998.

In accordance with Federal and State mandates the following services are covered:

 Reconstruction of the breast on which the mastectomy was performed
 Surgery and reconstruction of the other breast to produce a symmetrical appearance,

including nipple tattooing
 Prosthesis (Implanted and/or external)
 Treatment of physical complications of mastectomy, including lymphedema

Various surgical techniques are used for breast reconstruction, including but not limited to:

 Insertion of FDA approved breast implants and tissue expanders
 Breast Implants and tissue expanders post mastectomy with or without skin

substitutes, approved by the FDA, including but not limited to: Alloderm, Allomax or
FlexHD are a covered benefit
 Transverse Rectus Abdominus Myocutaneous Flap (TRAM)
 Latissimus Dorsi Flap (LD)
 Deep Inferior Epigastric Perforator (DIEP) Flap

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 Gluteal Flap (GAP free flap)

Refer to the Definitions section for breast reconstruction procedure definitions.

If the original implant or reconstructive surgery was considered reconstructive surgery by Oxford,
coverage may exist for removal, replacement and/or reconstruction. If the original implant or
reconstructive surgery was considered reconstructive surgery under the Oxford benefit document,
then removal of a ruptured prosthesis is treating a "complication arising from a medical or surgical
intervention." Removal or replacement of an implant that is not ruptured and unassociated with
local breast complications may not be covered.

Additional Information:
An in-network exception may be granted if there is not an in-network provider able to provide the
requested reconstructive procedure. Refer to the Member specific benefit document and the In-
Network Exceptions for Breast Reconstruction Surgery Following Mastectomy policy for
information regarding coverage from non-network providers.

Breast reconstruction may be covered under certain circumstances for the surgical treatment
of gender dysphoria. Please refer to the member’s specific benefit document for coverage
determination.

Treatments for complications post mastectomy

1. Lymphedema:

a. Complex Decongestive Physiotherapy (CDP) is covered for the complication of
lymphedema post mastectomy

b. Lymphedema pumps when required are covered
c. Compression Lymphedema sleeves are covered
d. Elastic bandages and wraps associated with covered treatments for the

complications of lymphedema

2. Treatment of a post operative infection(s).

3. Removal of a ruptured breast implant (either silicone or saline) is reconstructive for
implants done post mastectomy. Placement of a new breast implant will be covered if the
original implantation was done post mastectomy or for a covered reconstructive health
service.

Coverage Limitations and Exclusions

Please refer to Member’s state mandates and Member specific benefit documents.

1. Insertion of breast implants or reinsertion of breast implants for the purpose of improving
appearance is a cosmetic procedure unless covered under a state or federal mandate.

Note: If the breast reconstruction has been successfully completed post mastectomy and
the Member chooses to enlarge their breasts for cosmetic reasons, this is considered a
cosmetic service and is not covered.

2. Breast reconstruction or scar revision after breast biopsy or removal of a cyst with or
without a biopsy usually does not meet the definition of a covered reconstructive health
service. Refer to the Member’s specific benefit documents and state mandates.

3. Tissue protruding at the end of a scar (“dog ear”/standing cone), painful scars or donor
site scar revisions must be reviewed to determine if the procedure meets reconstructive
guidelines.

4. Liposuction other than to achieve breast symmetry during post mastectomy
reconstruction is considered cosmetic and is not covered.

5. Revision of prior reconstructed breast due to normal aging does not meet the definition of
a covered reconstructive health service.

6. Not medically necessary services.

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DEFINTIONS

Breast Reconstruction Steps:

STEP 1: Creation of a breast mound:

Reposition a woman’s own muscle, fat and skin to create a breast mound.

 TRAM Flap - the muscle, fat and skin from the lower abdomen is used to reconstruct the
breast.

 DIEP or SGAP Flap – the fat and skin but not muscle is used from the lower abdomen or
buttocks to reconstruct the breast.

 LATISSIUMS DORSI Flap – the muscle, fat and skin from the back are used to
reconstruct the breast may also need a breast implant.

Tissue expansion is used to stretch the skin to provide coverage for a breast implant to create a
breast mound.

 Requires several office visits over 4-6 months to fill the device through an internal valve
to expand the skin.

 A second surgical procedure is needed to replace the expander.

Surgical placement of a breast implant creates a breast mound.

 May be used with a flap or alone following tissue expansion.
 Silicone and saline implants are available for reconstruction.
 Reconstruction alone may be done with an implant but usually as tissue expander is

needed.

STEP 2: Creation of a nipple and areola:

 Many different techniques are used.
 Tattooing may be used for the areola.

Deep Inferior Epigastric Perforator (DIEP) Flap: The DIEP flap technique uses abdominal skin
and subcutaneous tissue while sparing the rectus abdominus muscle. Blood vessels, called deep
inferior epigastric perforators (DIEP), with the overlying skin and fat supplied by them, are
removed from the lower abdomen and transferred to the chest to reconstruct a breast after
mastectomy.

Gluteal Artery Perforator (GAP) Free Flap:

 Superior Gluteal Artery Perforator (S-GAP) Flap: The superior gluteal artery perforator
flap involves microsurgical transfer of skin and fat from the buttock without muscle
sacrifice. The flap is vascularized by one single perforator originating from the superior
gluteal artery.

 Inferior Gluteal Artery Perforator (I-GAP) Free Flap: The IGAP is harvested using the
same microsurgical, muscle-sparing techniques as the DIEP and S-GAP flaps.

Latissimus Dorsi Flap (LD): The LD flap moves muscle (and skin if required) from the back to
reconstruct the breast. It may be transferred as a free tissue transfer or rotated into place as a
pedicle flap to reconstruct the breast.

Mastectomy: Mastectomy includes partial (lumpectomy, tylectomy, quadrantectomy, and
segmentectomy), simple, and radical. A mastectomy does not include aspirations, biopsy (open
or core), excision of cysts, fibroadenomas or other benign or malignant tumors, aberrant breast
tissue, duct lesions, nipple or areolar lesions, and treatment of gynecomastia.

"Stacked" DIEP Flap: This procedure allows for incorporation of more abdominal fatty tissue
than conventional TRAM procedures or unilateral DIEP flap procedures.

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Superficial Inferior Epigastric Artery (SIEA) Flap: Replaces the skin and soft tissue removed
at mastectomy with skin and fatty tissue harvested from the abdomen.

Transverse Rectus Abdominus Myocutaneous (TRAM) Flap: The surgeon takes muscle and
overlying lower abdominal tissue and moves it to the chest area. TRAM flap may be done as
either a pedicle flap or a free flap.

Women's Health and Cancer Rights Act of 1998, § 713 (a): "In general - a group health plan,
and a health insurance issuer providing health insurance coverage in connection with a group
health plan, that provides medical and surgical benefits with respect to a mastectomy shall
provide, in case of a participant or beneficiary who is receiving benefits in connection with a
mastectomy and who elects breast reconstruction in connection with such mastectomy, coverage
for (1) reconstruction of the breast on which the mastectomy has been performed; (2) surgery and
reconstruction of the other breast to produce symmetrical appearance; and (3) prostheses and
physical complications all stages of mastectomy, including lymphedemas in a manner determined
in consultation with the attending physician and the patient."

APPLICABLE CODES

The Current Procedural Terminology (CPT®) codes and Healthcare Common Procedure Coding
System (HCPCS) codes listed in this policy are for reference purposes only. Listing of a service
code in this policy does not imply that the service described by this code is a covered or non-
covered health service. Coverage is determined by the member specific benefit document and
applicable laws that may require coverage for a specific service. The inclusion of a code does not
imply any right to reimbursement or guarantee claims payment. Other policies and coverage
determination guidelines may apply. This list of codes may not be all inclusive.

Mastectomy CPT Codes

CPT® Code Description
19301
Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy,
19302
19303 segmentectomy)
19304
19305 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy,
19306
segmentectomy); with axillary lymphadenectomy
19307
Mastectomy, simple, complete

Mastectomy, subcutaneous

Mastectomy, radical, including pectoral muscles, axillary lymph nodes

Mastectomy, radical, including pectoral muscles, axillary and internal

mammary lymph nodes (Urban type operation)

Mastectomy, modified radical, including axillary lymph nodes, with or

without pectoralis minor muscle, but excluding pectoralis major

muscle

CPT® is a registered trademark of the American Medical Association.

The following CPT codes do not meet criteria for post mastectomy (do not apply to breast
reconstruction).

CPT® Code Description
19100 Biopsy of breast; percutaneous, needle core, not using imaging
19101 guidance (separate procedure)
19120 Biopsy of breast; open, incisional
Excision of cyst, fibroadenoma, or other benign or malignant tumor,
19125 aberrant breast tissue, duct lesion, nipple or areolar lesion (except
19300), open, male or female, one or more lesions
19126 Excision of breast lesion identified by preoperative placement of
radiological marker, open; single lesion
Excision of breast lesion identified by preoperative placement of
radiological marker, open; each additional lesion separately identified
by a preoperative radiological marker (List separately in addition to

Breast Reconstruction Post Mastectomy: Clinical Policy (Effective 01/01/2016) 5
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CPT® Code Description
code for primary procedure)
21555 Excision tumor, soft tissue of neck or thorax; subcutaneous
21556 Excision tumor, soft tissue of neck or thorax; deep, subfascial,
intramuscular

Breast Reconstruction Post Mastectomy CPT Codes

CPT® Code Description

Tattooing, intradermal introduction of insoluble opaque pigments to

11920 correct color defects of skin, including micropigmentation; 6.0 sq cm

or less

Tattooing, intradermal introduction of insoluble opaque pigments to

11921 correct color defects of skin, including micropigmentation; 6.1 to 20.0

sq cm

Tattooing, intradermal introduction of insoluble opaque pigments to

11922 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)

11970 Replacement of tissue expander with permanent prosthesis

11971 Removal of tissue expander(s) without insertion of prosthesis

Application of skin substitute graft to trunk, arms, legs, total wound

15271 surface area up to 100 sq cm; first 25 sq cm or less wound surface

area

Application of skin substitute graft to trunk, arms, legs, total wound

15272 surface area up to 100 sq cm; each additional 25 sq cm wound
surface area, or part thereof (List separately in addition to code for

primary procedure)

Implantation of biologic implant (eg, acellular dermal matrix) for soft

15777 tissue reinforcement (ie, breast, trunk) (List separately in addition to

code for primary procedure)

19316 Mastopexy

19324 Mammaplasty, augmentation; without prosthetic implant

19325 Mammaplasty, augmentation; with prosthetic implant

19340 Immediate insertion of breast prosthesis following mastopexy,
mastectomy or in reconstruction

19350 Nipple/areola reconstruction

19357 Breast reconstruction, immediate or delayed, with tissue expander,
including subsequent expansion

19361 Breast reconstruction with latissimus dorsi flap, without prosthetic
implant

19364 Breast reconstruction with free flap

19366 Breast reconstruction with other technique

Breast reconstruction with transverse rectus abdominis

19367 myocutaneous flap (TRAM), single pedicle, including closure of donor

site

Breast reconstruction with transverse rectus abdominis

19368 myocutaneous flap (TRAM), single pedicle, including closure of donor

site; with microvascular anastomosis (supercharging)

Breast reconstruction with transverse rectus abdominis

19369 myocutaneous flap (TRAM), double pedicle, including closure of

donor site

19380 Revision of reconstructed breast

19396 Preparation of moulage for custom breast implant

19499 Unlisted procedure, breast

The code below is covered only to achieve symmetry of the contralateral breast post

mastectomy

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CPT® Code Description
19318
Reduction mammoplasty

CPT® is a registered trademark of the American Medical Association.

Applicable HCPCS Code

HCPCS Code Description
L8600* Implantable breast prosthesis, silicone or equal

*Refer to policies:

 Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies, and
Repairs/Replacements

 Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs

Applicable ICD-9 Codes (Discontinued 10/01/15)
The following list of codes is provided for reference purposes only. Effective October 1, 2015, the
Centers for Medicare & Medicaid Services (CMS) implemented ICD-10-CM (diagnoses) and ICD-
10-PCS (inpatient procedures), replacing the ICD-9-CM diagnosis and procedure code sets.

ICD-9 codes will not be accepted for services provided on or after October 1, 2015.

ICD-9 Procedure Code Description
(Discontinued10/01/15)
Malignant neoplasm of nipple and areola of female breast
174.0 Malignant neoplasm of central portion of female breast
174.1 Malignant neoplasm of upper-inner quadrant of female breast
174.2 Malignant neoplasm of lower-inner quadrant of female breast
174.3 Malignant neoplasm of upper-outer quadrant of female breast
174.4 Malignant neoplasm of lower-outer quadrant of female breast
174.5 Malignant neoplasm of axillary tail of female breast
174.6 Malignant neoplasm of other specified sites of female breast
174.8 Malignant neoplasm of breast (female), unspecified site
174.9 Malignant neoplasm of nipple and areola of male breast
175.0 Secondary malignant neoplasm of breast
198.81 Carcinoma in situ of breast
233.0 Personal history of malignant neoplasm of breast
V10.3 Acquired absence of breast and nipple
V45.71 Encounter for breast reconstruction following mastectomy
V51.0

ICD-10 Codes
ICD-10-CM (diagnoses) and ICD-10-PCS (inpatient procedures) must be used to report services
provided on or after October 1, 2015.

ICD-10 codes will not be accepted for services provided prior to October 1, 2015

ICD-10 Description
Diagnosis Code
Malignant neoplasm of nipple and areola, right female breast
C50.011 Malignant neoplasm of nipple and areola, left female breast
C50.012 Malignant neoplasm of nipple and areola, unspecified female breast
C50.019 Malignant neoplasm of nipple and areola, right male breast
C50.021 Malignant neoplasm of nipple and areola, left male breast
C50.022 Malignant neoplasm of nipple and areola, unspecified male breast
C50.029 Malignant neoplasm of central portion of right female breast
C50.111 Malignant neoplasm of central portion of left female breast
C50.112 Malignant neoplasm of central portion of unspecified female breast
C50.119 Malignant neoplasm of central portion of right male breast
C50.121 Malignant neoplasm of central portion of left male breast
C50.122 Malignant neoplasm of central portion of unspecified male breast
C50.129

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ICD-10 Description
Diagnosis Code
Malignant neoplasm of upper-inner quadrant of right female breast
C50.211 Malignant neoplasm of upper-inner quadrant of left female breast
C50.212 Malignant neoplasm of upper-inner quadrant of unspecified female
breast
C50.219 Malignant neoplasm of upper-inner quadrant of right male breast
Malignant neoplasm of upper-inner quadrant of left male breast
C50.221 Malignant neoplasm of upper-inner quadrant of unspecified male
C50.222 breast
Malignant neoplasm of lower-inner quadrant of right female breast
C50.229 Malignant neoplasm of lower-inner quadrant of left female breast
Malignant neoplasm of lower-inner quadrant of unspecified female
C50.311 breast
C50.312 Malignant neoplasm of lower-inner quadrant of right male breast
Malignant neoplasm of lower-inner quadrant of left male breast
C50.319 Malignant neoplasm of lower-inner quadrant of unspecified male
breast
C50.321 Malignant neoplasm of upper-outer quadrant of right female breast
C50.322 Malignant neoplasm of upper-outer quadrant of left female breast
Malignant neoplasm of upper-outer quadrant of unspecified female
C50.329 breast
Malignant neoplasm of upper-outer quadrant of right male breast
C50.411 Malignant neoplasm of upper-outer quadrant of left male breast
C50.412 Malignant neoplasm of upper-outer quadrant of unspecified male
breast
C50.419 Malignant neoplasm of lower-outer quadrant of right female breast
Malignant neoplasm of lower-outer quadrant of left female breast
C50.421 Malignant neoplasm of lower-outer quadrant of unspecified female
C50.422 breast
Malignant neoplasm of lower-outer quadrant of right male breast
C50.429 Malignant neoplasm of lower-outer quadrant of left male breast
Malignant neoplasm of lower-outer quadrant of unspecified male
C50.511 breast
C50.512 Malignant neoplasm of axillary tail of right female breast
Malignant neoplasm of axillary tail of left female breast
C50.519 Malignant neoplasm of axillary tail of unspecified female breast
Malignant neoplasm of axillary tail of right male breast
C50.521 Malignant neoplasm of axillary tail of left male breast
C50.522 Malignant neoplasm of axillary tail of unspecified male breast
Malignant neoplasm of overlapping sites of right female breast
C50.529 Malignant neoplasm of overlapping sites of left female breast
Malignant neoplasm of overlapping sites of unspecified female breast
C50.611 Malignant neoplasm of overlapping sites of right male breast
C50.612 Malignant neoplasm of overlapping sites of left male breast
C50.619 Malignant neoplasm of overlapping sites of unspecified male breast
C50.621 Malignant neoplasm of unspecified site of right female breast
C50.622 Malignant neoplasm of unspecified site of left female breast
C50.629 Malignant neoplasm of unspecified site of unspecified female breast
C50.811 Malignant neoplasm of unspecified site of right male breast
C50.812 Malignant neoplasm of unspecified site of left male breast
C50.819 Malignant neoplasm of unspecified site of unspecified male breast
C50.821 Secondary malignant neoplasm of breast
C50.822 Lobular carcinoma in situ of unspecified breast
C50.829 Lobular carcinoma in situ of right breast
C50.911 Lobular carcinoma in situ of left breast
C50.912
C50.919
C50.921
C50.922
C50.929
C79.81
D05.00
D05.01
D05.02

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ICD-10 Description
Diagnosis Code
Intraductal carcinoma in situ of unspecified breast
D05.10 Intraductal carcinoma in situ of right breast
D05.11 Intraductal carcinoma in situ of left breast
D05.12 Other specified type of carcinoma in situ of unspecified breast
D05.80 Other specified type of carcinoma in situ of right breast
D05.81 Other specified type of carcinoma in situ of left breast
D05.82 Unspecified type of carcinoma in situ of unspecified breast
D05.90 Unspecified type of carcinoma in situ of right breast
D05.91 Unspecified type of carcinoma in situ of left breast
D05.92 Encounter for breast reconstruction following mastectomy
Z42.1 Personal history of malignant neoplasm of breast
Z85.3 Acquired absence of unspecified breast and nipple
Z90.10 Acquired absence of right breast and nipple
Z90.11 Acquired absence of left breast and nipple
Z90.12 Acquired absence of bilateral breasts and nipples
Z90.13

BACKGROUND

Breast reconstruction is the rebuilding of a breast. It involves using autologous tissue or
prosthetic material to construct a natural-looking breast. Often this includes the reformation of a
natural-looking areola and nipple. This procedure involves the use of implants or relocated flaps
of the patient's own tissue. Breast reconstruction is achieved through several plastic surgery
techniques that attempt to restore a breast to near normal shape, appearance and size.

This policy addresses breast reconstructive procedures following a mastectomy and treatments of
complications post mastectomy. For information regarding breast repair/reconstruction not
following a mastectomy, refer to the policy titled Breast Repair/ Reconstruction (Not Following
Mastectomy).

For additional information, please refer to the following related policies:

 In-Network Exceptions for Breast Reconstruction Surgery Following Mastectomy
 Breast Repair/ Reconstruction (Not Following Mastectomy)
 Cosmetic and Reconstructive Procedures
 Breast Reduction Surgery
 Gynecomastia
 Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies, and

Repairs/Replacements
 Pneumatic Compression Devices
 Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs
 Gender Dysphoria (Gender Identity Disorder) Treatment

REFERENCES

The foregoing Oxford policy has been adapted from an existing UnitedHealthcare national policy
that was researched, developed and approved by UnitedHealthcare Coverage Determination
Committee. [CDG.003.05, Effective 01/01/2016]

1. American Society of Plastic Surgeons. Breast Reconstruction Procedures Steps. Available
at: http://www.plasticsurgery.org. Accessed on September 3, 2015.

2. Federal Mandate: The Women's Health and Cancer Rights Act of 1998. (Reconstructive
Breast Surgery). September 9, 2002, Revision Date July 16, 2007.

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POLICY HISTORY/REVISION INFORMATION

Date Action/Description
01/01/2016
 Revised conditions of coverage/special considerations; added
language to indicate:
o Precertification is required for services covered under the
Member's General Benefits package when performed in
the office of a participating provider
o For Commercial plans, precertification is not required, but
is encouraged for out-of-network services performed in the
office that are covered under the Member's General
Benefits package; if precertification is not obtained, Oxford
may review for medical necessity after the service is
rendered

 Revised coverage rationale/indications for coverage;
o Updated list of services covered in accordance with
federal/state mandate; replaced “prosthesis (implanted or
external)” with “prosthesis (Implanted and/or external)”
o Added language to indicate breast reconstruction may be
covered under certain circumstances for the surgical
treatment of gender dysphoria (refer to the enrollee specific
benefit document for coverage determination)

 Updated supporting information to reflect the most current
background information and references

 Archived previous policy version SURGERY 095.10 T2

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