Description: Show 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:
**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 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
Non-Coverage Criteria for Insertion and Removal of Breast Implants
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:
Coding Section
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. "Current Procedural Terminology © American Medical Association. All Rights Reserved" History From 2014 Forward
Does Blue Cross Blue Shield il cover breast reduction?Breast reduction surgery is a covered benefit if determined medically necessary by an IPA Physician. Breast reconstruction post- mastectomy is also covered; the mastectomy need not have been performed while the member was enrolled in the HMO.
What does a breast implant warranty cover?Standard warranties for breast implants usually cover two things: the cost of the implant and a predetermined amount of financial assistance for any qualifying revision surgeries (usually due to implant rupture).
Do you get a guarantee with breast implants?The most likely warranty scenario you will encounter is an leaking breast implant 10 years or more after your breast augmentation. In this situation, all four manufacturer's standard warranties will provide you with a replacement implant plus an additional one if needed, for the other breast.
Can your body reject breast implants years later?If you're worried that your immune system could react to the implant and reject it, this won't happen. It's vital to know if you consider breast augmentation that modern implants are approved by the FDA and safe. This means there will never be a rejection or immune system reaction when the implants are put in the body.
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