Does blue cross blue shield cover breast reconstruction

This article is intended for HMO members enrolled in an employer health insurance plan.

It’s normal to be anxious if you find out you need to have a mastectomy. A mastectomy is the removal of one or both breasts. This procedure is most often performed to treat breast cancer. 

If you are facing this surgery, take some comfort in knowing that federal and state laws require health insurance companies to cover reconstructive surgery afterward.

Blue Cross and Blue Shield of Illinois (BCBSIL) provides coverage for:

• Recreating the breast that was removed
• Breast implants
• Surgery on the other breast for an even appearance
• Treatment of possible side effects of mastectomy, including lymphedema (fluid buildup that leads to swelling)

These procedures must be provided by a licensed physician and meet other requirements.

Your plan may also cover annual mammograms. Want to find out more? Just call us at the customer service number on your member ID card. 

Originally published 9/4/2020; Revised 2022

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3. BREAST IMPLANTS QUESTIONS

February 26, 2017

Asked By:

in Terrell, TX

My health insurance is an HMO plan. Is there a Dr. that has a monthly payment plan or any kind of special offer or assistance with the price of breast implants? This is all new to me & I've wanted implants since my teenage years. I'm 34 with 4 kids & a 34A. I don't know if silicone or saline is best & not sure on either a C or D cup. I'm currently pear shaped. Any advice? Sincerely, a mommy in need of a miracle

Note: We state whether or not the calendar year deductible applies for each benefit listed in this section.

Benefit Description

Reconstructive Surgery
Reconstructive surgical procedures, limited to:

• Surgery to correct a functional defect
   
• Surgery to correct a congenital anomaly (See Section 10, page 127, for definition.)
   
• Treatment to restore the mouth to a pre-cancer state
   
• All stages of breast reconstruction surgery following a mastectomy, such as:
   
  • Surgery to produce a symmetrical appearance of the patient’s breasts
     
  • Treatment of any physical complications, such as lymphedemas
    Notes:
     
    • Internal breast prostheses are paid as orthopedic and prosthetic devices; see Section 5(a). See Section 5(c) when billed by a facility.
       
    • If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.
       
• Surgery for placement of penile prostheses to treat erectile dysfunction

You Pay
Preferred: 30% of the Plan allowance (deductible applies)

Non-preferred (Participating/Non-participating): You pay all charges

Description:
A mastectomy is a surgical procedure designed to remove all or part of the breast.  It is typically performed for the treatment of breast cancer, breast disease or gynecomastia.  Reconstructive surgery following a mastectomy is typically a covered benefit.  Please see specific contract verbiage for exclusions, limitations and/or maximums.

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: 

• The procedure follows mastectomy. It may be performed at the time of the mastectomy or post-operatively, as long as the mastectomy was MEDICALLY NECESSARY (i.e., breast cancer or benign disease not responsive to conservative measures). Please see specific contract verbiage for exclusions or limitations.
• Augmentation mammaplasty, reduction mammaplasty and/or mastopexy may be considered a covered benefit for the non-diseasedbreast following a MEDICALLY NECESSARY mastectomy for the achievement of breast symmetry. 

**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
Breast implants are prostheses used for post mastectomy reconstruction or used for the enlargement of breasts that are typically cosmetic in nature. Breast implants used solely for cosmetic purposes are not a covered benefit. 

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 

• Insertion of a breast implant is a covered benefit when performed as part of post-surgical mastectomy reconstruction. Removal of breast implants is a covered benefit when it is medically necessary due to complications that are related to a covered indication. 

Non-Coverage Criteria for Insertion and Removal of Breast Implants

• Breast implants are not a covered benefit when used primarily for cosmetic purposes.
• Removal of breast implants is not a covered benefit when the patient is asymptomatic (i.e., pain, etc.).
• Removal of breast implants is not covered when the original implant was performed primarily for cosmetic purposes or for other non-covered indications in those contracts that specifically exclude complications of a non-covered service.

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:

1. The Blue Cross and Blue Shield Association, Reduction Mammoplasty; Original Policy Date: 12/95, Review Date: 4/03.
2. The Blue Cross and Blue Shield Association: Prophylactic Mastectomy; 12/99 Original Policy: Reviewed 2/03.
3. The Blue Cross and Blue Shield Association: Mastectomy for Gynecomastia; Original policy issued by the Blue Cross and Blue Association: Original Policy Date: 12/95, Review Date: 2/03.
4. The Blue Cross and Blue Shield Association: Reconstructive Breast Surgery/Management of Breast Implants 11/97; Original policy issued by the Blue Cross and Blue Shield Association; Original Policy Date: 11/97,  Review Date:  2/03.
5. Women's Health and Cancer Rights Act of 1998.
6. South Carolina Senate 13.19 Proposed Legislation (Omnibus Appropriations Bill); 10/98.
7. The New England Journal of Medicine: Complications Leading to Surgery after Breast Implants; 03/97.
8. Plastic Information Services, Breast Reconstruction; 06/99.
9. Methodist Health Care Systems, Breast Care-Post Mastectomy Prosthesis.  

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     

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