Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Reduction Mammoplasty

Policy #:11.08.02h

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.


MEDICALLY NECESSARY

REDUCTION MAMMOPLASTY
Reduction mammoplasty is considered medically necessary and, therefore, covered for either of the following indications:
  • When performed in conjunction with cancer surgery of one breast, to improve or correct asymmetry of the contralateral breast.
  • In individuals with macromastia or gigantomastia when both of the following criteria are met:
    • The individual meets the minimum specimen weight of breast tissue to be removed based on the individual's body surface area (BSA) and the Schnur scale (refer to Guideline section for Schnur Scale).
    • One of the following clinical symptoms is present for a minimum six-week period:
      • Back pain from macromastia unrelieved by conservative measures (e.g., support bra, exercise, heat/cold treatment, non-steroidal anti-inflammatory drugs [NSAIDs]/muscle relaxants) or physical therapy.
      • Significant arthritic changes in the cervical or upper thoracic spine that has not responded to conservative measures (e.g., support bra, exercise, heat/cold treatment, NSAIDs/muscle relaxants or physical therapy)
      • Intertriginous maceration, discoloration, chronic or recurrent infection of the inframammary skin refractory to dermatologic treatment measures that have not responded to a completed course of medical management.
      • Shoulder grooving to a depth greater than 1 cm with skin irritation or darkening that has not responded to appropriately fitted support garments.
      • Graphic documentation of ptosis with nipple areolar complex 8 cm below the inframammary crease.

COSMETIC

All other uses for reduction mammoplasty, such as but not limited to, the sole use of liposuction for reduction mammoplasty, reduction mammoplasty performed solely to remove fat and/or skin, or when the minimum specimen weight of breast tissue does not meet the medical necessity criteria as outlined above, are considered a cosmetic service. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

NOT MEDICALLY NECESSARY

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. Upon audit, if it is determined that the service performed is not consistent with the information presented at the time of precertification approval, the service will be considered Not Medically Necessary. As such, Claim retractions will occur based on a retrospective claim audit review. Providers will be notified prior to any retrospective payment retraction and be afforded the standard facility appeals review process for dispute resolution.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

All requests for reduction mammoplasty require review by the Company's cosmetic review team and must include documentation. This documentation is to include, but is not limited to: photographic confirmation of breast size; results of mammography as appropriate (e.g., when performed in conjunction with breast cancer surgery); medical records regarding previous treatment (e.g., dermatologic treatment measures for chronic or recurrent infection of the inframammary skin in individuals with macromastia); amount of breast tissue actually removed (i.e. pathology report) and other health care professional reports.
Guidelines

REDUCTION MAMMOPLASTY

The volume or weight of the potential breast tissue resection should be combined with other concurrent symptoms to determine the appropriateness of a reduction mammoplasty procedure for an individual.

The table below is an evaluation method (Schnur Sliding Scale Chart) for the minimum estimated specimen weight (in grams) of breast tissue that the surgeon will remove from each breast, based on the individual's BSA:

Simplified formula for calculation of body surface area:
BSA (in m2) = [height (cm)] 0.718 X [weight (kg)] 0.427 X .007449

See the web site for easy calculation: http://www.bcbst.com/providers/calculator.asp.

To convert weight in pounds to kilograms, multiply pounds by 0.45.

To convert height in inches to centimeters, multiply inches by 2.54.


Schnur Sliding Scale
BSA (m2)
Resected tissue weight; each breast in grams
1.40
220
1.45
240
1.50
260
1.55
285
1.60
310
1.65
340
1.70
370
1.75
405
1.80
440
1.85
480
1.90
525
1.95
575
2.00
630
2.05
685
2.10
750
2.15
820
2.20
895
2.25
980
2.30
1,070
2.35
1,165
2.40
1,275
2.45
1,395
2.50
1,520
2.55
1,660


BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, reduction mammoplasty is covered under the medical benefits of the Company's products when the medical necessity criteria listed in the medical policy are met. Individual benefits must be verified.

A cosmetic service is a benefit contract exclusion for all of the Company’s products.

CROSS-REFERENCE POLICIES

For information on reduction mammoplasty to correct an asymmetry due to a congenital defect or an abnormality, refer to the policy on reconstructive breast surgery.

Refer to the Cross References section in this policy for a list of Company policies that address services related to this topic, as well as links to summaries of any applicable mandate(s).

Description

Reduction mammoplasty is a surgical procedure used to treat female breast hypertrophy (i.e., macromastia or gigantomastia). The surgery involves the excision of a portion of the breast, including the skin and underlying glandular tissue, to reduce the size, shape, and weight of mammary tissue. Macromastia is defined as a marked, abnormally excessive, pendulous enlargement of one or both breasts. This condition may result in pain of the shoulder, neck, or back, nerve compression of the arms, and recurrent intertrigo in the mammary folds. Reduction mammoplasty can also be performed to alleviate symptoms for a rare condition called gigantomastia. To date, there is no universally acceptable definition for gigantomastia, and the exact cause of gigantomastia has not yet been determined; however, it is characterized by excessive breast growth that may occur spontaneously, during puberty, pregnancy, or while taking certain medication. Though reduction mammoplasty may be done at any age, it is usually performed when breast development is complete. In select cases (e.g., when the breasts are not too large and the skin has good elasticity), liposuction has been used as a sole method of treatment to reduce the overall breast size. However, in most cases, only fat, not glandular breast tissue, can be successfully removed by liposuction.

Schnur et al. (1991) developed a sliding scale based on a survey response from plastic surgeons who recorded the height, weight, and amount of breast tissue removed from each breast during reduction mammoplasty. The surgeons were also asked if the procedures were performed for cosmetic or medically necessary reasons. The data was used to create a chart relating the body surface area and the cut-off weight of breast tissue removed. The Schnur scale (abbreviated in the guidelines section) allows a rough estimate of the minimal amount of soft tissue to be removed to justify surgery to alleviate symptoms based on body surface area.

Kerrigan et al. (2002) published the results of the Breast Reduction: Assessment of Value and Outcomes (BRAVO) study, a registry of 179 women undergoing reduction mammoplasty. The participating women were asked to complete questionnaires addressing quality of life and physical symptoms both before and after surgery. The physical symptom evaluation focused on the number of symptoms that were specific to breast hypertrophy such as back pain, rashes, bra strap grooves, neck pain, shoulder pain, numbness, and arm pain. In addition, the weight and volume of resected breast tissue was documented. The results were compared to a control group of individuals with either breast hypertrophy or normal size breasts who were recruited from the general population. The authors proposed that the presence of at least two physical symptoms should be appropriate for determining medical necessity for breast reduction. The authors reported that while 71.6% of the hypertrophic control group reported zero or one symptom, only 12.4% of the surgical candidates reported zero or one symptom. This observation was difficult to evaluate because the study did not report how surgical candidacy was determined. The authors also reported that none of the traditional criteria for determining medical necessity for breast reduction surgery (e.g., height, weight, body mass index, bra cup size, or weight of resected tissue) had a statistically significant relationship with post-surgical symptom improvement. The authors concluded that the determination of medical necessity should be based on the individual's report of symptoms rather than more objectively measured criteria, such as estimated weight of excised breast tissue.

In 2008, a randomized controlled trial by Sabino Neto et al., assessed functional capacity of 100 individuals. Subjects were randomized to reduction mammoplasty or waiting list control. At the onset of study and six months later, individuals were assessed for functional capacity using the Roland-Morris Disability Questionnaire (0=best performance, 24=worst performance) and for pain using a visual analog scale (VAS). The reduction mammoplasty group showed improvement in functional status, with an average score of 5.9 preoperatively to 1.2 within 6 months postoperatively (p<0.001 for pre-post comparison within the mammoplasty group) versus an unchanged average score of 6.2 in control group on the first and second evaluations. Subjects in the reduction mammoplasty group also reported decrease in pain in the lower back region on the VAS from an average of 5.7 preoperatively to 1.3 postoperatively (p<0.001 for pre-post comparison within the mammoplasty group) versus VAS average score in the control group of 6.0 and 5.3 on the first and second evaluations respectively (no significant change).

Also in 2008, Saariniemi et al., reported on quality of life (QOL) and pain in 82 individuals who were randomized to reduction mammoplasty or a non-operative group and evaluated at baseline and six months later. At six months, the authors reported that the mammoplasty group had significant improvement in QOL as measured by Physical Component Summary score of the 36-Item Short-Form Health Survey (SF-36; change, +9.7 vs +0.7, p<0.001), the Utility Index score (SF-6D; change, +17.5 vs +0.6), the index score of QOL (SF-15D; change, +8.6 vs +0.06, p<0.001), and SF-36 Mental Component Summary score (change, +7.8 vs -1.0, p<0.002). The authors also reported improvements in breast-related symptoms, as reported by the Finnish Breast-Associated Symptoms questionnaire score and the Finnish Pain questionnaire score -47.9 vs -3.5, p<0.001 and 21.5 vs -1.0, p<0.001, respectively.

A 2012 systematic review of studies by Singh and Losken et al. reported on outcomes after reduction mammoplasty and found reduction mammoplasty improved functional outcomes, including pain, breathing, sleep, and headaches; the authors also reported on psychological outcomes and reported improvements in self-esteem, sexual function, and QOL in addition to less anxiety and depression.

A systematic review by Thibaudeau et al, was conducted in 2010 to evaluate breastfeeding after reduction mammoplasty. The authors reviewed literature from 1950 through 2008 and concluded that reduction mammoplasty does not reduce the ability to breastfeed. The authors reported similar rates of breastfeeding in women who had reduction mammoplasty in the first month postpartum to the general population in North America.

In 2016, Beraldo et al., assessed the sexual function and depression outcomes among individuals with breast hypertrophy undergoing reduction mammoplasty in a randomized trial of 60 individuals. At six months, the authors reported higher Female Sexual Function Index scores in the reduction mammoplasty group versus the no surgery group (27.5 vs 22.5, p<0.001) and lower levels of depression as measured by the Beck Depression Inventory in the reduction mammoplasty group versus the no surgery group (7.2 vs 13.7, p=0.01).

In 2016, Hernanz et al reported on a descriptive cohort study of 37 consecutive obese patients who underwent reduction mammoplasty for symptomatic macromastia, along with 37 age-matched women hospitalized for short-stay surgical procedures. In the preoperative state, SF-36 physical health component subscore was significantly lower for patients with symptomatic macromastia (40) than for age-matched controls (53; p<0.001), with differences in 5 of the 8 subscales. At 18 months post-procedure, there was no significant difference in any SF-36 subscores except the body pain subscale between patients who had undergone reduction mammoplasty and age-matched controls.

Overall, reduction mammoplasty in appropriately selected individuals is associated with improvements in several health outcomes. However, the criteria for medically necessary reduction mammoplasty are not well addressed in current professional literature. Therefore, patient selection criteria cannot rely solely on an evidence-based approach. Relevant studies indicate that functional limitations related to breast hypertrophy are improved following reduction mammoplasty. Volume or weight of the potential breast tissue resection should be combined with other concurrent symptoms to determine the appropriateness of reduction mammoplasty for an individual.

Current literature suggests that a baseline mammogram should be performed before the mammoplasty because mammographic findings after this surgery are predictable. Having a baseline reading prevents unnecessary biopsies and assists with diagnosing lesions unrelated to the procedure.
References


American Society of Plastic Surgeons. Evidence-based Clinical Practice Guideline: Reduction Mammaplasty. [American Society of Plastic Surgeons Web site]. 2011. Available at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Reduction_Mammaplasty_Evidence_Based_Guideline%20%282%29%282%29.pdf. Accessed January 25, 2018.

American Society of Plastic Surgeons. Reduction Mammaplasty: ASPS Recommended Insurance Coverage Criteria for Third-Party Payers. [American Society of Plastic Surgeons Web site]. May 2011. Available at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/insurance/Reduction_Mammaplasty_Coverage_Criteria.pdf. Accessed January 25, 2018.

American Society of Plastic Surgeons (ASPS). ASPS recommended insurance coverage criteria for third-party payers. Gynecomastia. [American Society of Plastic Surgeons Web site]. March 2002. Available at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/insurance/Gynecomastia-Insurance-Coverage.pdf. Accessed January 25, 2018.

American Society of Plastic Surgeons (ASPS). Evidence-based guidelines/practice parameters. Gynecomastia. [American Society of Plastic SurgeonsASPS Web site]. February 2004. Available at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Gynecomastia-PP.pdf. Accessed January 25, 2018.

Beraldo, Flávia NM, et al. Sexual function and depression outcomes among breast hypertrophy patients undergoing reduction mammaplasty: a randomized controlled trial. Annals of plastic surgery. 2016;76(4):379-82.

Botta SA. Alternatives for the surgical correction of severe gynecomastia. Aesthetic Plast Surg. 1998;22(1):65-70.

Braunstein GD. Diagnosis and treatment of gynecomastia. Hosp Pract. 1993;28(10A):37-46.

Chadbourne, EB, Zhang S, Gordon MJ, et al. Clinical outcomes in reduction mammoplasty: a systematic review and meta-analysis of published studies. Mayo Clin Proc.2001:76(5)503-10.

Chen CL, Shore AD, Johns R, et al. The impact of obesity on breast surgery complications. Plast Reconstr Surg. 2011;128(5):395e-402e.

Collins ED, Kerrigan CL, Kim M, et al. The effectiveness of surgical and nonsurgical interventions in relieving the symptoms of macromastia. Plast Reconstr Surg. 2002;109(5):1556-1566.

Cordova A, Moshella F. Algorithm for clinical evaluation and surgical treatment of gynaecomastia. J. Plastic Aesthet Surg. 2008;61(1):41-9.

Cunningham BL, Gear AJ, Kerrigan CL, Collins ED. Analysis of breast reduction complications derived from the BRAVO study. Plast Reconstr Surg. 2005;115(6):1597-604.

Dabbah A, Lehman JA Jr, Parker MG, et al. Reduction mammoplasty: An outcome analysis. Ann Plast Surg. 1995;35(4):337-341.

Danikas D, Theodorou SJ, Kokkalis G, et al. Mammographic findings following reduction mammoplasty. Aesthetic Plast Surg.2001:25(4):283-5.

Frantz AG. Endocrine disorders of the breast. In: Wilson JD, Foster DW, Kronenberg HM, Larsen PR, eds. Williams Textbook of Endocrinology. 9th ed. Philadelphia, PA: WB Saunders Company; 1998: 886-887.

Geiker NR, Horn J, Astrup A. Preoperative weight loss program targeting women with overweight and hypertrophy of the breast - a pilot study. Clin Obes. 2017;7(2):98-104.

Ginkas P, Mokbel K. Management of gynecomastia: An update. [Medscape Web site]. 08/06/07. Available at: http://cme.medscape.com/viewarticle/560809 [via subscription only]. [The link to this reference is no longer active on the Medscape Web site.]. Accessed January 31, 2017.

Glass AR. Gynecomastia. Endocrinol Metab Clin North Am. 1994;23(4):825-837.

Glass G, Soldin M. The effect of new inclusion criteria on patient selection for reduction mammoplasty. Department of Plastic and Reconstructive Surgery, London, UK. Clinical Governance: An International Journal. 2007;12(1):6-12.

Glatt BS, Sarwer DB, O'Hara DE, et al. A retrospective study of changes in physical symptoms and body image after reduction mammoplasty. Plast Reconstr Surg. 1999;103(1):76-85.

Hage JJ, Karim RB. Risk of breast cancer among reduction mammoplasty patients and the strategies used by plastic surgeons to detect such cancer. Plast Reconstr Surg.2006;117(3):727-736.

Hernanz F, Fidalgo M, Munoz P, et al. Impact of reduction mammoplasty on the quality of life of obese patients suffering from symptomatic macromastia: A descriptive cohort study. J Plast Reconstr Aesthet Surg. 2016;69(8):e168-173.

Hidalgo DA, Elliot LF, Palumbo S, et al. Current trends in breast reduction. Plast Reconstr Surg. 1999;104(3):806-815.

Iwuagwu OC, Platt AJ, Stanley PW, et al. Does reduction mammaplasty improve lung function test in women with macromastia? Results of a randomized controlled trial. Plast Reconstr Surg. 2006;118(1):1-6; discussion 7.

Iwuagwu OC, Walker LG, Stanley PW, et al. Randomized clinical trial examining psychosocial and quality of life benefits of bilateral breast reduction surgery. Br J Surg. 2006;93(3):291-294.

Kalliainen LK. ASPS Clinical Practice Guideline Summary on Reduction Mammaplasty. Plast Reconstr Surg. 2012;130(4):785-789.

Kauf E. Gynecomastia in childhood. Pathological causes unusual but serious. Fortschur Med. 1998;116(35-36):23-26.

Kerrigan CL, Collins ED, Kim HM, et al. Reduction mammoplasty: Defining medical necessity. Med Decis Making. 2002;22(3):208-217.

Krieger LM, Lesavoy MA. Managed care's methods for determining coverage of plastic surgery procedures: The example of reduction mammoplasty. Plast Reconstr Surg. 2001;107(5);1234-1240.

Kumar RJ, Barqawi A, Crawford ED. Adverse events associated with hormonal therapy for prostate cancer. Rev Urol. 2005;7 Suppl 5:S37-S43.

Miller BJ, Morris SF, Sigurdson LL, et al. Prospective study of outcomes after reduction mammoplasty. Plast Reconstr Surg. 2005;115(4):1025-1031.

Myung Y, Heo CY. Relationship Between Obesity and Surgical Complications After Reduction Mammaplasty: A Systematic Literature Review and Meta-Analysis. Aesthet Surg J. 2017;37(3):308-315.

National Center for Advancing Translational Science. Genetic and Rare Disease Information Center. Gigantomastia. [National Institutes of Health Web site]. Last updated 10/05/2016. Available at: https://rarediseases.info.nih.gov/gard/9450/gigantomastia/resources/8. Accessed January 25, 2018.

Nelson JA, Fischer JP, Chung CU, et al. Obesity and early complications following reduction mammaplasty: An analysis of 4545 patients from the 2005-2011 NSQIP datasets. J Plast Surg Hand Surg. 2014;48(5):334-339.

Neuman JF. Evaluation and treatment of gynecomastia. Am Fam Physician.1997;55(5):1835-1844, 1849-1850.

Nordt CA, DiVasta AD. Gynecomastia in adolescents. Curr Opin Pediatr. 2008;20(4):375-382.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L35090: Cosmetic and reconstructive surgery. [Novitas Solutions Web site]. Original: 10/01/2015. (Revised: 04/14/2017). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35090&ver=36&Date=12%2f31%2f2015&DocID=L35090&bc=iAAAAAgBAAAA&. Accessed January 25, 2018.

Nuzzi LC, Firriolo JM, Pike CM, et al. The Effect of Reduction Mammaplasty on Quality of Life in Adolescents With Macromastia. Pediatrics. 2017;140(5). pii: e20171103.

Pensler JM, Delgado, Jr MA, Yost MJ. Plastic surgery for gynecomastia. [eMedicine Web site]. 01/17/2016. Available at: http://emedicine.medscape.com/article/1273437-overview. Accessed January 25, 2018.

Schnur PL. Reduction mammoplasty - the Schnur sliding scale revisited. Ann Plast Surg. 1999;42(1);107-108.

Schnur PL, Hoehn JG, llstrup D, et al. Reduction mammoplasty: cosmetic or reconstructive procedure? Ann Plast Surg. 1991;27(3):232-237.

Schnur PL, Schnur DP, Petty PM, et al. Reduction mammoplasty: an outcome study. Plast Reconstr Surg. 1997;100(4):875-883.

Sabino Neto M, Dematte MF, Freire M, et al. Self-esteem and functional capacity outcomes following reduction mammaplasty. Aesthetic Surg J. 2008;28(4):417-420.

Saariniemi KM, Keranen UH, Salminen-Peltola PK, et al. Reduction mammaplasty is effective treatment according to two quality of life instruments. A prospective randomised clinical trial. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2008;61(12):1472-8.

Shermak MA, Chang D, Buretta K, et al. Increasing age impairs outcomes in breast reduction surgery. Plast Reconstr Surg. 2011;128(6):1182-1187.

Singh KA, Losken A. Additional benefits of reduction mammaplasty: a systematic review of the literature. Plastic Reconstruct Surg. 2012;129(3):562-570.

Thibaudeau S, Sinno H, Williams B. The effects of breast reduction on successful breastfeeding: a systematic review. J Plastic Reconstruct Aesthet Surg. 2010;63(10):1688-1693.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

15877, 19318


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

THE FOLLOWING IS USED TO REPORT MEDICALLY NECESSARY CRITERIA USING PRIMARY DIAGNOSIS AND CLINICAL SYMPTOMS


PRIMARY DIAGNOSIS
N62 Hypertrophy of breast

CLINICAL SYMPTOMS
L26 Exfoliative dermatitis
L30.4 Erythema intertrigo
L54 Erythema in diseases classified elsewhere
L95.1 Erythema elevatum diutinum
L98.2 Febrile neutrophilic dermatosis [Sweet]
M25.511 Pain in right shoulder
M25.512 Pain in left shoulder
M54.2 Cervicalgia
M54.6 Pain in thoracic spine
M54.9 Dorsalgia, unspecified
N64.81 Ptosis of breast
N65.1 Disproportion of reconstructed breast
R21 Rash and other nonspecific skin eruption
Z48.3 Aftercare following surgery for neoplasm



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 11.08.02h
06/05/2019This policy has been reissued in accordance with the Company's annual review process.
05/07/2018This version of the policy will become effective 05/07/2018. The intent of this policy remains unchanged. In Guidelines sections, revised parameters to consistently follow rounding convection when discrepancies noted from source.

The following CPT code has been removed from this policy: 15777


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 05/07/2018
Version Issued Date: 05/07/2018
Version Reissued Date: 06/05/2019

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