REVIEW REQUEST FOR

Breast Procedures: Including Reconstructive

Surgery, Implants and Other Breast Procedures

Provider Data Collection Tool Based on Medical Policy SURG.00023

Policy Last Review Date: 07/26/2018 / Policy Effective Date: 08/02/2018 / Provider Tool Effective Date: 08/02/2018
Individual’s Name: / Date of Birth:
Insurance Identification Number: / Individual’s Phone Number:
Ordering Provider Name & Specialty: / Provider ID Number:
Office Address:
Office Phone Number: / Office Fax Number:
Rendering Provider Name & Specialty: / Provider ID Number:
Office Address:
Office Phone Number: / Office Fax Number:
Facility Name: / Facility ID Number:
Facility Address:
Date/Date Range of Service: / Place of Service: Home Inpatient
Outpatient Other:
Service Requested (CPT if known):
Diagnosis Code(s) (if known):

This medical policy based data collection tool is for medical necessity review for reconstructive breast surgery, cosmetic surgeries designed to enhance the appearance of the breast and management of breast implants.

Note: Please see the following related document(s) for additional information:

  • SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
  • CG-SURG-71 Reduction Mammaplasty

For information regarding surgical procedures of the breast for individuals with gender dysphoria/incongruence or gender identity disorder (GID), please see the following:

  • CG-SURG-27 Sex Reassignment Surgery

Please mark all that apply to the indivual:

Reconstructive Breast Surgery

Request is for reconstructive breast surgerytorebuild the normal contour of the affectedand the contralateral unaffected breast to produce a more normal appearance following a mastectomy, lumpectomy or other breast surgery to treat breast cancer

(If checked, please mark all of the following that apply to the individual)

Procedure is for reconstructive surgeryand implant insertion

Procedure involves the individual’s muscle tissue being transposed from another site

Procedure is for reconstruction of the contralateral breast to achieve symmetry with

reduction mammaplasty, augmentation mammaplasty with implants, or mastopexy

Procedure is a revision or removal of pre-existing breast implants placed for cosmetic

purposes

Request is for surgery to reconstruct both breasts following a bilateral mastectomy

Request is for surgery to alter the contour of the breast for significant abnormalities related to trauma,

congenital defects, infection or other non-malignant disease

(If checked, please mark all of the following that apply to the individual)

The individual has a congenital absence or hypoplasia of pectoralis major and minor muscles

The individual has breast hypoplasia

The individual has a congenital partial absence of the upper costal cartilage

Other (Please List):______

Management of Breast Implants

Request is for the surgical removal of apartially or completelyfilledSilicone Gel implant due to

a documented rupture of the implant on imaging (mammography, ultrasound, or MRI)

Request is to remove a Silicone Gel, Saline-filled or “Alternative” implant:

(If checked, please mark all of the following that apply to the individual)

due to an infection of the implant or surrounding tissue

due to exposure/extrusion

due topain related to Baker Class IV capsular contracture

forconfirmed cases of breast implant-associated anaplastic large cell lymphoma

prior to surgical treatment for breast cancer

Request is for removal of an implant (ANY TYPE)withor without reimplantation, originally

placed in an individual with a history of mastectomy, lumpectomy or treatment of breast cancer for

reconstructive purposes, due to development of a visible distortion (Baker Class III contracture)

Request is for removalof a Saline-filled or “Alternative" implant with or without reimplantation,

originally placed in an individual with a history of mastectomy, lumpectomy or treatment of breast

cancer for reconstructive purposes, due to implant rupture

Request is for removal of a ruptured Saline-filled or “Alternative” implant for potential adverse

medical consequences related to implant rupture

Request is for removal of ANY TYPE ofbreast implant:

(If checked, please mark all of the following that apply to the individual)

due tosystemic symptoms attributed to connective tissue disease, autoimmune diseases, etc.

due topersonal anxiety

due topain not related to contractures or rupture

Other (Please List):______

Cosmetic Surgeries

Request is for reimplantation of an implant inserted for cosmetic purposes only (that is, for reasons other than a history of mastectomy, lumpectomy, treatment of breast cancer, significant abnormalities related to trauma, congenital defects, infection or other non-malignant disease) removed as part of a reconstructive surgery

Request is for augmentation mammaplasty

Request is for breast lift

Request is for implant repositioning

Request is for repair of inverted nipples

Request is for mastopexy

Other (Please List):______

This request is being submitted:

Pre-Claim

Post–Claim. (If checked, please attach the claim or indicate the claim number)

I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its designees may perform a routine audit and request the medical documentation to verify the accuracy of the information reported on this form.

Name and Title of Provider or Provider Representative CompletingDate

Form and Attestation (Please Print)*

*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted.

Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization management services on behalf of your health benefit plan or the administrator of your health benefit plan.