Health First Breast Surgery Form

Reconstructive Breast Surgery

Reconstructive Breast Surgery may be considered medically necessary when the clinical criteria in this Policy are met.

Description:

The American Society of Plastic Surgeons (ASPS) indicates that breast surgery falls into two main categories, which are cosmetic surgery and reconstructive surgery. Cosmetic surgery is performed to reshape and adjust normal structures of the body to enhance the visual appearance and is not covered by Health First Health Plans. Reconstructive surgery is performed to restore and improve function and correct any deformities or abnormal structures of the body that have been caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. This policy will deal with medically necessary breast surgeries that are deemed to be reconstructive in nature.

Definitions:

• Gynecomastia: Hypertrophy of glandular tissue of male mammary glands. Note: Certain HFHP policies exclude breast surgery for gynecomastia (IFP). Members will need to check for exclusions within their contract.
• Macromastia: The development of abnormally large breasts in the female (aka breast hypertrophy)
• Mastectomy: Surgery to remove all breast tissue from a breast as a way to treat or prevent breast cancer.
• Mastopexy: Mammoplasty procedure for raising sagging breasts upon the chest of the woman (aka breast lift)
• Reconstructive surgery - Breast surgery that restores and improves function and corrects any deformities or abnormal structures of the body that have been caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. For the purposes of this policy, reconstructive breast surgery may include medically necessary breast reduction, post mastectomy breast reconstruction, or medically necessary removal of breast implants.
• Reduction Mammaplasty: The surgical (generally bilateral) removal of a substantial portion of the breast, including the skin and underlying glandular tissue, until a clinically normal size is obtained.

Clinical Criteria:

(Indications/Limitations)

1. Breast Reconstruction Following Mastectomy
   1. Reconstruction of affected breast following removal of breast for any medical reason
   2. Reconstruction of contralateral unaffected breast following removal of a breast for any medical reason
2. Macromastia

   Reduction mammaplasty for macromastia is considered medically necessary when all of the criteria (A-E) below are met:

   1. Breast size interferes with activities of daily living, as indicated by 1 or more of the following:
      1. Arm numbness consistent with brachial plexus compression syndrome
      2. Cervical pain
      3. Chronic breast pain
      4. Headaches
      5. Nipple position greater than 21 cm below suprasternal notch
      6. Persistent redness and erythema (intertrigo) below breasts
      7. Restriction of physical activity
      8. Severe bra strap grooving or ulceration of shoulder
      9. Shoulder pain Thoracic kyphosis
      10. Upper or lower back pain
      11. To reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery. Note: either the involved breast or contralateral breast may be treated to achieve symmetry
   2. Preoperative evaluation by surgeon concludes that amount of breast tissue to be removed (by mass or volume) will provide reasonable expectation of symptomatic relief.
   3. No evidence of breast cancer. NOTE: Women aged 40 and older must have a mammogram that was negative for cancer within one year prior to the planned surgery.
   4. Photographic documentation confirms severe breast hypertrophy.
   5. Member’s physician has determined and documented that:
      1. Symptoms are primarily due to macromastia; and
      2. Breast reduction surgery is likely to result in improvement to symptoms; and
      3. The member’s surgeon estimates that the amounts of breast tissue to be removed from each breast is consistent with the Schnur Scale below.
         
3. Removal of Breast Implants - Only for placement related to breast reconstruction related to breast cancer or prophylactic mastectomy
   1. The removal of breast implant(s) is considered medically reasonable and necessary for the treatment of any one or more of the following conditions:
   2. Broken or failed implant
   3. Infection or inflammatory reaction due to breast prosthesis; including infected breast implant, or rejection of breast implants.
   4. Implant extrusion
   5. Siliconoma or granuloma
   6. Painful capsular contracture with disfigurement NOTE: Commercial Plans do not cover removal breast implants when placed for cosmetic purposes
4. Gynecomastia - Male
   1. Mastectomy for gynecomastia may be indicated for 1 or more of the following:
   2. Postpubertal male and ALL of the following:
      1. Functional impairment (i.e., chronic skin irritation, pain, related psychological disorder requiring therapy)
      2. When applicable, Gynecomastia did not regress after cessation of medications (i.e., calcium channel blockers, cimetidine, phenothiazines, spironolactone, theophylline) known to cause condition, medications cannot be discontinued, or no medications that induce gynecomastia are being used.
      3. No evidence of breast cancer
      4. No evidence of medical causes for gynecomastia, as indicated by normal results for ALL of the following:

3. Pubertal male and ALL the following:
   1. Functional impairment (i.e, chronic skin irritation, pain, related psychological disorder requiring therapy)
   2. Gynecomastia present for 2 or more years
   3. Gynecomastia with grade 3 to 4 of severity:
      • Grade I: Minimal hypertrophy (<250 g) without ptosis
      • Grade II: Moderate hypertrophy (250-500 g) without ptosis
      • Grade III: Severe hypertrophy (>500 g) with grade I ptosis
      • Grade IV: Severe hypertrophy with grade II or grade III ptosis

• Hormone evaluation (i.e., testosterone, luteinizing hormone, follicle- stimulating hormone, estradiol, prolactin, beta-human chorionic gonadotropin)
• Liver enzymes
• Serum creatinine
• iv. tests

Limitations:

(Not Covered)

1. Surgery to reshape the breasts to improve appearance or self-image.
2. Re-implantation of an implant inserted for cosmetic purposes only (that is, for reasons other than a history of mastectomy for treatment of breast cancer, lumpectomy, or treatment of contralateral breast to bring it into symmetry with a breast reconstructed after cancer surgery).
3. Mastopexy unrelated to medically necessary breast reconstruction
4. Male breast reduction or surgical mastectomy for gynecomastia, either unilateral or bilateral, as the first line treatment.
5. When performed solely to improve appearance of the male breast or to alter contours of the chest wall.