NCD 140.2

Item/Service Description

During recent years, there has been a considerable change in the treatment of diseases of the breast such as fibrocystic disease and cancer. While extirpation of the disease remains of primary importance, the quality of life following initial treatment is increasingly recognized as of great concern. The increased use of breast reconstruction procedures is due to several factors:

• A change in epidemiology of breast cancer, including an apparent increase in incidence;

• Improved surgical skills and techniques;

• The continuing development of better prostheses; and

• Increasing awareness by physicians of the importance of postsurgical psychological adjustment.

Indications and Limitations of Coverage

Reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is considered a relatively safe and effective noncosmetic procedure. Accordingly, program payment may be made for breast reconstruction surgery following removal of a breast for any medical reason.

Program payment may not be made for breast reconstruction for cosmetic reasons. (Cosmetic surgery is excluded from coverage under §l862(a)(l0) of the Act.)

Revision History

04/1997 - Indicated that reconstruction of affected breast and contralateral unaffected breast following a medically necessary mastectomy are covered, and deleted references to ICD-9-CM codes. Effective date 01/01/1997. (TN 96)

08/1989 - Clarified coverage following a medically necessary mastectomy, and included applicable ICD-9-CM and HCPCS codes. Effective date NA. (TN 40)