Does blue cross blue shield cover preventive mastectomy

It's been an up and down couple of weeks for Carmen Severino.

Table of Contents Show

Is a preventive mastectomy covered by insurance?
Who qualifies for preventive mastectomy?
Does Anthem Blue Cross Blue Shield cover prophylactic mastectomy?
When is prophylactic mastectomy medically necessary?

The 60-year-old Naperville resident was diagnosed with right breast cancer in February. After months of chemotherapy, she opted to undergo a bilateral mastectomy and have both her cancerous and healthy breast removed and reconstructed.

"For my peace of mind, just take them both," the married mother and grandmother said. "Why wait and have something happen two or three years down the road, and go through chemo again? I can't go through chemo again."

Her surgery was delayed, however, because Blue Cross and Blue Shield of Illinois initially would not cover the removal of her healthy breast, a procedure known as a contralateral prophylactic mastectomy.

"I was devastated," said Severino, who shared her story on social media at https://www.facebook.com/breastcancerexperience. "I took to my bed for two days, just crying, and really scared."

But a week later, on the afternoon of Aug. 12, Blue Cross and Blue Shield approved the coverage, saying the company updated its policy to cover contralateral prophylactic mastectomy. She had the surgery Aug. 19.

Severino's husband, David Eisen, said Thursday that the surgery went well, and that no evidence was found that the cancer had spread to her lymph nodes.

Blue Cross and Blue Shield of Illinois spokeswoman Maryann Schultz said the company's contralateral prophylactic mastectomy police change went into effect on Aug. 11.

Before the policy change, Severino did not meet the insurer's high-risk criteria for a prophylactic mastectomy, and the procedure in her circumstances was considered "experimental, investigational and/or unproven," Schultz said.

Severino's doctors and surgeons at the DuPage Medical Group and Edward Hospital refused comment on Severino's case.

"The policy was expanded, and (contralateral prophylactic mastectomy) may be considered medically necessary for women who have been diagnosed with breast cancer in the opposite breast," Schultz said.

The policy's previous iteration required things like genetic testing and a family history of cancer in order for the company to approve a prophylactic mastectomy like Severino's, according to Schultz.

Such coverage policy reviews are conducted monthly, with the topics scheduled months in advance, Schultz said.

Blue Cross and Blue Shield of Illinois has 495 medical polices, according to Schultz, with 121 of them reviewed and updated in the past three months.

"This member issue wasn't discussed during the policy review and the timing was irrelevant," Schultz said. "They aren't related."

Severino said she was anxious enough about the surgery, but did not want to have only one reconstructed breast.

"Reconstruction does not leave pretty breasts," she said. "But when you have clothes on, you still feel like a woman."

Twitter: @JournoGeoffZ

Description:
A mastectomy is a surgical procedure designed to remove all or part of the breast. It is typically performed for the treatment of breast cancer, breast disease or gynecomastia. Reconstructive surgery following a mastectomy is typically a covered benefit. Please see specific contract verbiage for exclusions, limitations and/or maximums.

PRIOR AUTHORIZATION MUST BE OBTAINED FOR MEDICAL NECESSITY IN ORDER TO BE CONSIDERED FOR REIMBURSEMENT OF THE PLAN BENEFITS, UNLESS OTHERWISE INDICATED BY THE SPECIFIC CONTRACT VERBIAGE.

POLICY

Reconstructive surgery performed following a mastectomy is a covered benefit. The procedure typically includes the reconstruction of the mastectomy site, creation of a new breast mound, along with the creation of a new nipple/areolar complex. It may also include reconstruction of the non-diseased breast to achieve symmetry. Such procedures may include, but are not limited to, DIEP, GIEP or the SGAP procedure. Nipple tattooing is considered to be an integral part of the nipple/areolar reconstructive procedure and not reimbursed as a separate service but rather as part of the whole procedure.

Reconstructive breast surgery is a covered benefit when the following criteria are met:

The procedure follows mastectomy. It may be performed at the time of the mastectomy or post-operatively, as long as the mastectomy was MEDICALLY NECESSARY (i.e., breast cancer or benign disease not responsive to conservative measures). Please see specific contract verbiage for exclusions or limitations.
Augmentation mammaplasty, reduction mammaplasty and/or mastopexy may be considered a covered benefit for the non-diseasedbreast following a MEDICALLY NECESSARY mastectomy for the achievement of breast symmetry.

**All reconstructive surgery, including but not limited to mastectomy, augmentation mammaplasty, reduction mammaplasty and/or mastopexy, must have prior authorization.**

Insertion and Removal of Breast Implants
Breast implants are prostheses used for post mastectomy reconstruction or used for the enlargement of breasts that are typically cosmetic in nature. Breast implants used solely for cosmetic purposes are not a covered benefit.

A breast prosthesis can be used either internally or externally. For internal usage, the breast implant is placed into the breast area once the natural breast tissue has been removed. External usage is accomplished by wearing a specially fitted brassiere. One external prosthesis per year may be allowed without review; however, more than one external prosthesis per year must be reviewed for medical necessity. Up to four (4) prosthetic bras per year will be allowed without individual consideration and review. Please review specific contract verbiage for exclusions, limitations and/or maximums.

Coverage Criteria for Insertion and Removal of Breast Implants

Insertion of a breast implant is a covered benefit when performed as part of post-surgical mastectomy reconstruction. Removal of breast implants is a covered benefit when it is medically necessary due to complications that are related to a covered indication.

Non-Coverage Criteria for Insertion and Removal of Breast Implants

Breast implants are not a covered benefit when used primarily for cosmetic purposes.
Removal of breast implants is not a covered benefit when the patient is asymptomatic (i.e., pain, etc.).
Removal of breast implants is not covered when the original implant was performed primarily for cosmetic purposes or for other non-covered indications in those contracts that specifically exclude complications of a non-covered service.

PRIOR AUTHORIZATION MUST BE OBTAINED FOR MEDICAL NECESSITY IN ORDER TO BE CONSIDERED FOR REIMBURSEMENT OF THE PLAN OF BENEFITS, UNLESS OTHERWISE INDICATED BY THE SPECIFIC CONTRACT.

Scientific Background and Reference Sources:

The Blue Cross and Blue Shield Association, Reduction Mammoplasty; Original Policy Date: 12/95, Review Date: 4/03.
The Blue Cross and Blue Shield Association: Prophylactic Mastectomy; 12/99 Original Policy: Reviewed 2/03.
The Blue Cross and Blue Shield Association: Mastectomy for Gynecomastia; Original policy issued by the Blue Cross and Blue Association: Original Policy Date: 12/95, Review Date: 2/03.
The Blue Cross and Blue Shield Association: Reconstructive Breast Surgery/Management of Breast Implants 11/97; Original policy issued by the Blue Cross and Blue Shield Association; Original Policy Date: 11/97, Review Date: 2/03.
Women's Health and Cancer Rights Act of 1998.
South Carolina Senate 13.19 Proposed Legislation (Omnibus Appropriations Bill); 10/98.
The New England Journal of Medicine: Complications Leading to Surgery after Breast Implants; 03/97.
Plastic Information Services, Breast Reconstruction; 06/99.
Methodist Health Care Systems, Breast Care-Post Mastectomy Prosthesis.

Coding Section

Codes	Number	Description
CPT	00402	Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; reconstructive procedures on breast (e.g., reduction or augmentation mammoplasty, muscle flaps)
	00404	Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified radical procedures on breast
	00406	Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified radical procedures on breast with internal mammary node dissection
	11920	Tattooing, Intradermal Introduction of Insoluble Opaque Pigments to Correct Color Defects of Skin, including Micropigmentation; 6.0² cm or less
	11921	Tattooing, Intradermal Introduction of Insoluble Opaque Pigments to Correct Color Defects of Skin, including Micropigmentation, 6.1 to 20.0²cm
	11922	Tattooing, Intradermal Introduction of Insoluble Opaque Pigments to Correct Color Defects of Skin, including Micropigmentation; each
	11970	Replacement of tissue expander with permanent prosthesis
	11971	Removal of tissue expander(s) without insertion of prosthesis
	15271	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
	15272	Application of skin substitute graft to trunk, arms, legs, total wound 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)
	15777	Implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement (i.e., breast, trunk) (list separately in addition to code for primary procedure)
	15877	Suction assisted lipectomy; trunk
	17999	Unlisted procedure, skin, mucous membrane and subcutaneous tissue
	19316	Mastopexy
	19318	Reduction mammaplasty
	19324	Mammaplasty, Augmentation; Without Prosthetic Implant
	19325	Mammaplasty, Augmentation; With Prosthetic Implant
	19328	Removal of intact mammary implant
	19330	Removal of mammary implant material
	19340	Immediate Insertion of Breast Prosthesis Following Mastopexy, Mastectomy or Reconstruction
	19342	Delayed Insertion of Breast Prosthesis Following Mastopexy, Mastectomy or In Reconstruction
	19350	Nipple/Areola Reconstruction
	19355	Correction of inverted nipples
	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
	19367	Breast Reconstruction with Transverse Rectus Abdomins Myocutaneous Flap (Tram), Single Pedicle, Including Closure of Donor Site
	19368	Breast Reconstruction with Transverse Rectus Abdomins Myocutaneous Flap (Tram), Single Pedicle, Including Closure of Donor Site; With Microvascular Anastomosis (Supercharging)
	19369	Breast Reconstruction with Transverse Rectus Abdomins Myocutaneous Flap (Tram), Double Pedicle, Including Closure of Donor Site
	19370	Open periprosthetic capsulectomy, breast
	19371	Periprosthetic capsulectomy, breast
	19380	Revision of Reconstructed Breast
	19396	Preparation of Moulage for Custom Breast Implant
	19499	Unlisted procedure, breast
ICD-9 Diagnosis	174-174.9	Malignant Neoplasm of Female Breast
	175-175.9	Malignant Neoplasm of Male Breast
	198.81	Secondary Malignant Neoplasm of Other Specified Sites, Breast
	233	Carcinoma in situ of breast and genitourinary system, Breast
	234.8	Carcinoma in situ of other specified sites
	234.9	Carcinoma in situ, site unspecified
	V10.3	Personal History of Malignant Neoplasm, Breast
	V16.3	Family history of malignant neoplasm of breast
	V43.82	Breast replacement
	V45.71	Acquired Absence of Breast
	V50.41	Prophylactic breast removal
	V51.0	Encounter for breast reconstruction following mastectomy
	V52.4	Fitting and adjustment of breast prosthesis and implant
HCPCS	C1789	Prosthesis, breast (implantable)
	L8600	Implantable breast prosthesis, silicone or equal
	S2066	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 breast, unilateral
	S2067	Breast reconstruction of a single breast 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 breast, unilateral
	S2068	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 breast, unilateral
ICD-10-CM (effective 10/01/15)	C50.01-C50.119	Malignant neoplasm of nipple and areola, unspecified female breast
	C50.2-C50.219	Malignant neoplasm of upper-inner quadrant of breast, unspecified female breast
	C50.3-C50.319	Malignant neoplasm of lower-inner quadrant of breast, unspecified female breast
	C50.4-C50.419	Malignant neoplasm of upper-outer quadrant of breast, unspecified female breast
	C50.5-C50.519	Malignant neoplasm of lower-outer quadrant of breast, unspecified female breast
	C50.6-C50.619	Malignant neoplasm of axillary tail of breast, unspecified female breast
	C50.8-C50.819	Malignant neoplasm of overlapping sites of breast, unspecified female breast
	C50.9-C50.919	Malignant neoplasm of breast of unspecified site, unspecified female breast
	C50.029	Malignant neoplasm of nipple and areola, unspecified male breast
	C50.929	Malignant neoplasm of unspecified site of unspecified male breast
	C79.81	Secondary malignant neoplasm of breast
	D05.90	Unspecified type of carcinoma in situ of unspecified breast
	D09.3	Carcinoma in situ of thyroid and other endocrine glands
	D09.8	Carcinoma in situ of other specified sites
	D09.9	Carcinoma in situ, unspecified
	Z85.3	Personal history of malignant neoplasm of breast
	Z80.3	Family history of malignant neoplasm of breast
	Z98.82	Breast implant status
	Z90.10	Acquired absence of unspecified breast and nipple
	Z90.11	Acquired absence of right breast and nipple
	Z90.12	Acquired absence of left breast and nipple
	Z90.13	Acquired absence of bilateral breasts and nipples
	Z40.01	Encounter for prophylactic removal of breast
	Z42.1	Encounter for breast reconstruction following mastectomy
	Z44.30	Encounter for fitting and adjustment of external breast prosthesis, unspecified breast

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

History From 2014 Forward

09/07/2022	Annual review, no change to policy intent,
09/01/2021	Annual review, no change to policy intent.
09/01/2020	Annual review, no change to policy intent.
09/01/2019	Annual review, no change to policy intent.
09/05/2018	Annual review, no change to policy intent.
09/07/2017	Annual review, no change to policy intent.
09/01/2016	Annual review, no change to policy intent. Updating coding.
09/17/2015	Annual review, no change to policy intent. Adding coding.
09/11/2014	Annual review. No changes made to policy.

Is a preventive mastectomy covered by insurance?

Insurance coverage No federal laws require insurance companies to cover prophylactic mastectomy. Some state laws require coverage for prophylactic mastectomy, but coverage varies state to state. It's best to check with your insurance company to learn about your plan's coverage. Learn more about health insurance.

Who qualifies for preventive mastectomy?

According to the National Cancer Institute, only those women who are at very high risk of breast cancer should consider preventive mastectomy. This includes women with one or more of the following risk factors: BRCA or certain other gene mutations. Strong family history of breast cancer.

Does Anthem Blue Cross Blue Shield cover prophylactic mastectomy?

Prophylactic mastectomy is covered. No preauthorization is required. Coverage: Benefits may vary between groups/contracts.

When is prophylactic mastectomy medically necessary?

Prophylactic mastectomies may be performed in women considered at high risk of developing breast cancer, either due to a family history, presence of a BRCA1, BRCA2, TP53, PTEN or PALB2 gene mutation, or the presence of lesions associated with an increased cancer risk.

blue cross blue shield cover preventive mastectomy