PA Lookup

Breast reconstructive surgery is performed following a mastectomy to establish symmetry with the contralateral breast or following bilateral mastectomy. It includes creation of a new breast mound and nipple-areolar reconstruction. Reconstructive surgery may also include reduction mammaplasty, mastopexy, or augmentation on the contralateral breast to establish symmetry; breast implants, tissue flaps, or both may be placed where natural breast tissue has been removed.

Limits

Breast implants are not covered when used for breast enlargement for cosmetic purposes.

Removal of mammary implants or mammary implant material is not covered for cosmetic purposes.

Augmentation mammaplasty with or without prosthesis is not covered for cosmetic purposes.

Correction of inverted nipples is not covered.

Preparation of moulage for custom breast implants is not covered.

Periprosthetic capsulotomy and periprosthetic capsulectomy following augmentation are not covered.

Mastopexy is not covered except when the criteria for breast reconstructive surgery are met.

Services are also not covered when the beneficiary does not meet eligibility requirements, does not meet Section 3.0 criteria, the service duplicates another provider's service, or the service is experimental, investigational, or part of a clinical trial.

Exclusions

Male Gynecomastia-Service is for male beneficiaries; the description specifies surgical removal of breast tissue from adult males.

Adult pathway requires persistence for more than 3 to 4 months after pathological causes are ruled out.

Adolescent pathway requires persistence for more than 6 months after pathological causes are ruled out.

For male gynecomastia specifically, coverage is not supported when the breast enlargement is due to normal transient pubertal enlargement, obesity or fatty rather than glandular tissue, drug treatments that resolve when stopped, medications, non-covered therapies, alcohol, or illicit drugs such as marijuana or anabolic steroids.

Fibrocystic disease is not a legitimate reason for prophylactic mastectomy in the absence of documented risk factors.

Place of Service

Inpatient hospital, Outpatient hospital, Office

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-12
• Records Management and Documentation Manual

Breast reconstructive surgery is performed following a mastectomy to establish symmetry with the contralateral breast or following bilateral mastectomy. It includes creation of a new breast mound and nipple-areolar reconstruction. Reconstructive surgery may also include reduction mammaplasty, mastopexy, or augmentation on the contralateral breast to establish symmetry; breast implants, tissue flaps, or both may be placed where natural breast tissue has been removed.

Limits

Breast implants are not covered when used for breast enlargement for cosmetic purposes.

Removal of mammary implants or mammary implant material is not covered for cosmetic purposes.

Augmentation mammaplasty with or without prosthesis is not covered for cosmetic purposes.

Correction of inverted nipples is not covered.

Preparation of moulage for custom breast implants is not covered.

Periprosthetic capsulotomy and periprosthetic capsulectomy following augmentation are not covered.

Mastopexy is not covered except when the criteria for breast reconstructive surgery are met.

Services are also not covered when the beneficiary does not meet eligibility requirements, does not meet Section 3.0 criteria, the service duplicates another provider's service, or the service is experimental, investigational, or part of a clinical trial.

Exclusions

Male Gynecomastia-Service is for male beneficiaries; the description specifies surgical removal of breast tissue from adult males.

Adult pathway requires persistence for more than 3 to 4 months after pathological causes are ruled out.

Adolescent pathway requires persistence for more than 6 months after pathological causes are ruled out.

For male gynecomastia specifically, coverage is not supported when the breast enlargement is due to normal transient pubertal enlargement, obesity or fatty rather than glandular tissue, drug treatments that resolve when stopped, medications, non-covered therapies, alcohol, or illicit drugs such as marijuana or anabolic steroids.

Fibrocystic disease is not a legitimate reason for prophylactic mastectomy in the absence of documented risk factors.

Place of Service

Inpatient hospital, Outpatient hospital, Office

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-12
• Records Management and Documentation Manual

Breast reconstructive surgery is performed following a mastectomy to establish symmetry with the contralateral breast or following bilateral mastectomy. It includes creation of a new breast mound and nipple-areolar reconstruction. Reconstructive surgery may also include reduction mammaplasty, mastopexy, or augmentation on the contralateral breast to establish symmetry; breast implants, tissue flaps, or both may be placed where natural breast tissue has been removed.

Limits

Breast implants are not covered when used for breast enlargement for cosmetic purposes.

Removal of mammary implants or mammary implant material is not covered for cosmetic purposes.

Augmentation mammaplasty with or without prosthesis is not covered for cosmetic purposes.

Correction of inverted nipples is not covered.

Preparation of moulage for custom breast implants is not covered.

Periprosthetic capsulotomy and periprosthetic capsulectomy following augmentation are not covered.

Mastopexy is not covered except when the criteria for breast reconstructive surgery are met.

Services are also not covered when the beneficiary does not meet eligibility requirements, does not meet Section 3.0 criteria, the service duplicates another provider's service, or the service is experimental, investigational, or part of a clinical trial.

Exclusions

Male Gynecomastia-Service is for male beneficiaries; the description specifies surgical removal of breast tissue from adult males.

Adult pathway requires persistence for more than 3 to 4 months after pathological causes are ruled out.

Adolescent pathway requires persistence for more than 6 months after pathological causes are ruled out.

For male gynecomastia specifically, coverage is not supported when the breast enlargement is due to normal transient pubertal enlargement, obesity or fatty rather than glandular tissue, drug treatments that resolve when stopped, medications, non-covered therapies, alcohol, or illicit drugs such as marijuana or anabolic steroids.

Fibrocystic disease is not a legitimate reason for prophylactic mastectomy in the absence of documented risk factors.

Place of Service

Inpatient hospital, Outpatient hospital, Office

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-12
• Records Management and Documentation Manual

Breast reconstructive surgery is performed following a mastectomy to establish symmetry with the contralateral breast or following bilateral mastectomy. It includes creation of a new breast mound and nipple-areolar reconstruction. Reconstructive surgery may also include reduction mammaplasty, mastopexy, or augmentation on the contralateral breast to establish symmetry; breast implants, tissue flaps, or both may be placed where natural breast tissue has been removed.

Limits

Breast implants are not covered when used for breast enlargement for cosmetic purposes.

Removal of mammary implants or mammary implant material is not covered for cosmetic purposes.

Augmentation mammaplasty with or without prosthesis is not covered for cosmetic purposes.

Correction of inverted nipples is not covered.

Preparation of moulage for custom breast implants is not covered.

Periprosthetic capsulotomy and periprosthetic capsulectomy following augmentation are not covered.

Mastopexy is not covered except when the criteria for breast reconstructive surgery are met.

Services are also not covered when the beneficiary does not meet eligibility requirements, does not meet Section 3.0 criteria, the service duplicates another provider's service, or the service is experimental, investigational, or part of a clinical trial.

Exclusions

Male Gynecomastia-Service is for male beneficiaries; the description specifies surgical removal of breast tissue from adult males.

Adult pathway requires persistence for more than 3 to 4 months after pathological causes are ruled out.

Adolescent pathway requires persistence for more than 6 months after pathological causes are ruled out.

For male gynecomastia specifically, coverage is not supported when the breast enlargement is due to normal transient pubertal enlargement, obesity or fatty rather than glandular tissue, drug treatments that resolve when stopped, medications, non-covered therapies, alcohol, or illicit drugs such as marijuana or anabolic steroids.

Fibrocystic disease is not a legitimate reason for prophylactic mastectomy in the absence of documented risk factors.

Place of Service

Inpatient hospital, Outpatient hospital, Office

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-12
• Records Management and Documentation Manual

Breast reconstructive surgery is performed following a mastectomy to establish symmetry with the contralateral breast or following bilateral mastectomy. It includes creation of a new breast mound and nipple-areolar reconstruction. Reconstructive surgery may also include reduction mammaplasty, mastopexy, or augmentation on the contralateral breast to establish symmetry; breast implants, tissue flaps, or both may be placed where natural breast tissue has been removed.

Authorization Guidelines

Prior approval is required for mastectomy for male gynecomastia. The following medical documentation must be submitted with the completed prior approval form:

• a. Height (in inches), weight (in pounds), and age;
• b. Unclothed pre-operative photographs from the chin to the waist (or lowest extent of

breasts, if lower), including standing frontal and side views with arms straight down at the sides;

• c. Medical record documentation of objective signs and symptoms and their duration;

prior medical management, including the beneficiary’s current medications;

endocrine study results; and confirmation that the excessive tissue is glandular;

• d. A list of subjective symptoms caused by breast enlargement with supporting

medical record documentation of significant medical symptoms;

• e. Evidence of exclusion of other medical problems that may cause or contribute to the

significant medical symptoms as documented in the medical record; and

• f. Medical record documentation by the requesting surgeon that the excessive breast

tissue is not caused by medications, non-covered therapies, alcohol, or usage of illicit drugs such as marijuana or anabolic steroids.

Prophylactic mastectomy requires prior approval. The requesting physician shall submit the following medical documentation with a completed prior approval request form:

• a. History and physical;
• b. Diagnoses;
• c. Medical records to demonstrate the criteria; and
• d. Plan of treatment, containing any planned reconstruction.

Reduction Mammaplasty Reduction mammaplasty requires prior approval when performed as part of reconstructive surgery that meets requirements; .d.

Breast Reconstructive Surgery Certain breast reconstructive surgeries require prior approval.

Conditional Requirements

No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.

Limits

Breast implants are not covered when used for breast enlargement for cosmetic purposes.

Removal of mammary implants or mammary implant material is not covered for cosmetic purposes.

Augmentation mammaplasty with or without prosthesis is not covered for cosmetic purposes.

Correction of inverted nipples is not covered.

Preparation of moulage for custom breast implants is not covered.

Periprosthetic capsulotomy and periprosthetic capsulectomy following augmentation are not covered.

Mastopexy is not covered except when the criteria for breast reconstructive surgery are met.

Services are also not covered when the beneficiary does not meet eligibility requirements, does not meet Section 3.0 criteria, the service duplicates another provider's service, or the service is experimental, investigational, or part of a clinical trial.

Exclusions

Male Gynecomastia-Service is for male beneficiaries; the description specifies surgical removal of breast tissue from adult males.

Adult pathway requires persistence for more than 3 to 4 months after pathological causes are ruled out.

Adolescent pathway requires persistence for more than 6 months after pathological causes are ruled out.

For male gynecomastia specifically, coverage is not supported when the breast enlargement is due to normal transient pubertal enlargement, obesity or fatty rather than glandular tissue, drug treatments that resolve when stopped, medications, non-covered therapies, alcohol, or illicit drugs such as marijuana or anabolic steroids.

Fibrocystic disease is not a legitimate reason for prophylactic mastectomy in the absence of documented risk factors.

Place of Service

Inpatient hospital, Outpatient hospital, Office

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

• Trillium iTransact Portal
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No: 1A-12
• Records Management and Documentation Manual

Breast reconstructive surgery is performed following a mastectomy to establish symmetry with the contralateral breast or following bilateral mastectomy. It includes creation of a new breast mound and nipple-areolar reconstruction. Reconstructive surgery may also include reduction mammaplasty, mastopexy, or augmentation on the contralateral breast to establish symmetry; breast implants, tissue flaps, or both may be placed where natural breast tissue has been removed.

Authorization Guidelines

Prior approval is required for mastectomy for male gynecomastia. The following medical documentation must be submitted with the completed prior approval form:

• a. Height (in inches), weight (in pounds), and age;
• b. Unclothed pre-operative photographs from the chin to the waist (or lowest extent of

breasts, if lower), including standing frontal and side views with arms straight down at the sides;

• c. Medical record documentation of objective signs and symptoms and their duration;

prior medical management, including the beneficiary’s current medications;

endocrine study results; and confirmation that the excessive tissue is glandular;

• d. A list of subjective symptoms caused by breast enlargement with supporting

medical record documentation of significant medical symptoms;

• e. Evidence of exclusion of other medical problems that may cause or contribute to the

significant medical symptoms as documented in the medical record; and

• f. Medical record documentation by the requesting surgeon that the excessive breast

tissue is not caused by medications, non-covered therapies, alcohol, or usage of illicit drugs such as marijuana or anabolic steroids.

Prophylactic mastectomy requires prior approval. The requesting physician shall submit the following medical documentation with a completed prior approval request form:

• a. History and physical;
• b. Diagnoses;
• c. Medical records to demonstrate the criteria; and
• d. Plan of treatment, containing any planned reconstruction.

Reduction Mammaplasty Reduction mammaplasty requires prior approval when performed as part of reconstructive surgery that meets requirements; .d.

Breast Reconstructive Surgery Certain breast reconstructive surgeries require prior approval.

Conditional Requirements

No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.

Limits

Breast implants are not covered when used for breast enlargement for cosmetic purposes.

Removal of mammary implants or mammary implant material is not covered for cosmetic purposes.

Augmentation mammaplasty with or without prosthesis is not covered for cosmetic purposes.

Correction of inverted nipples is not covered.

Preparation of moulage for custom breast implants is not covered.

Periprosthetic capsulotomy and periprosthetic capsulectomy following augmentation are not covered.

Mastopexy is not covered except when the criteria for breast reconstructive surgery are met.

Services are also not covered when the beneficiary does not meet eligibility requirements, does not meet Section 3.0 criteria, the service duplicates another provider's service, or the service is experimental, investigational, or part of a clinical trial.

Exclusions

Male Gynecomastia-Service is for male beneficiaries; the description specifies surgical removal of breast tissue from adult males.

Adult pathway requires persistence for more than 3 to 4 months after pathological causes are ruled out.

Adolescent pathway requires persistence for more than 6 months after pathological causes are ruled out.

For male gynecomastia specifically, coverage is not supported when the breast enlargement is due to normal transient pubertal enlargement, obesity or fatty rather than glandular tissue, drug treatments that resolve when stopped, medications, non-covered therapies, alcohol, or illicit drugs such as marijuana or anabolic steroids.

Fibrocystic disease is not a legitimate reason for prophylactic mastectomy in the absence of documented risk factors.

Place of Service

Inpatient hospital, Outpatient hospital, Office

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

• Trillium iTransact Portal
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No: 1A-12
• Records Management and Documentation Manual

Breast reconstructive surgery is performed following a mastectomy to establish symmetry with the contralateral breast or following bilateral mastectomy. It includes creation of a new breast mound and nipple-areolar reconstruction. Reconstructive surgery may also include reduction mammaplasty, mastopexy, or augmentation on the contralateral breast to establish symmetry; breast implants, tissue flaps, or both may be placed where natural breast tissue has been removed.

Limits

Breast implants are not covered when used for breast enlargement for cosmetic purposes.

Removal of mammary implants or mammary implant material is not covered for cosmetic purposes.

Augmentation mammaplasty with or without prosthesis is not covered for cosmetic purposes.

Correction of inverted nipples is not covered.

Preparation of moulage for custom breast implants is not covered.

Periprosthetic capsulotomy and periprosthetic capsulectomy following augmentation are not covered.

Mastopexy is not covered except when the criteria for breast reconstructive surgery are met.

Services are also not covered when the beneficiary does not meet eligibility requirements, does not meet Section 3.0 criteria, the service duplicates another provider's service, or the service is experimental, investigational, or part of a clinical trial.

Exclusions

Male Gynecomastia-Service is for male beneficiaries; the description specifies surgical removal of breast tissue from adult males.

Adult pathway requires persistence for more than 3 to 4 months after pathological causes are ruled out.

Adolescent pathway requires persistence for more than 6 months after pathological causes are ruled out.

For male gynecomastia specifically, coverage is not supported when the breast enlargement is due to normal transient pubertal enlargement, obesity or fatty rather than glandular tissue, drug treatments that resolve when stopped, medications, non-covered therapies, alcohol, or illicit drugs such as marijuana or anabolic steroids.

Fibrocystic disease is not a legitimate reason for prophylactic mastectomy in the absence of documented risk factors.

Place of Service

Inpatient hospital, Outpatient hospital, Office

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-12
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required

Authorization Guidelines

No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required. Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

No pre-authorization required for all providers when billed with a Breast cancer Dx. For all others, authorization is required.

How to Submit

If applicable, please submit your request to Trillium.

• Trillium iTransact Portal

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required