Mastopexy Product Applicability

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Medical Policy

Mastopexy

Policy Number: OCA 3.717 Version Number: 13 Version Effective Date: 05/08/17

Product Applicability All Plan+ Products

Well Sense Health Plan Boston Medical Center HealthNet Plan New Hampshire Medicaid MassHealth NH Health Protection Program Qualified Health Plans/ConnectorCare/Employer Choice Direct Senior Care Options ◊

Notes: + Disclaimer and audit information is located at the end of this document. ◊ The guidelines included in this Plan policy are applicable to members enrolled in Senior Care Options only if there are no criteria established for the specified service in a Centers for Medicare & Medicaid Services (CMS) national coverage determination (NCD) or local coverage determination (LCD) on the date of the prior authorization request. Review the member’s product-specific benefit documents at www.SeniorsGetMore.org to determine coverage guidelines for Senior Care Options.

Policy Summary Mastopexy or breast lift surgery is considered medically necessary for specific medical conditions when Plan criteria are met. The Plan complies with coverage guidelines for all applicable state-mandated benefits and federally-mandated benefits that are medically necessary for the member’s condition. Plan prior authorization is required for mastopexy. If applicable medical criteria are NOT met, the surgery is considered cosmetic.

In accordance with Massachusetts state-mandated benefits, the Plan covers medically necessary treatment to correct or repair disturbances of body composition caused by HIV-associated lipodystrophy syndrome for a BMC HealthNet Plan member (i.e., Massachusetts resident enrolled in

Mastopexy

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan. 1 of 16

the Plan’s MassHealth, Qualified Health Plans, or Senior Care Options product). Review the Gynecomastia Surgery medical policy (policy number OCA 3.48) for medical necessity criteria for gynecomastia surgery (including but not limited to the surgical treatment for gynecomastia to reduce HIV-associated lipohypertrophy of the chest). See the Plan medical policy, Cosmetic, Reconstructive, and Restorative Services (policy number OCA 3.69), rather than this policy for medical necessity criteria for the following indications for treatments: Treatment of HIV-associated lipodystrophy when it is not associated with gynecomastia surgery (e.g., liposuction/suction assisted lipectomy, autologous fat grafts, reconstructive breast procedures, and/or dermal filler injections for the treatment of facial lipoatrophy syndrome) and/or the treatment of lipodystrophy when the condition is not associated with HIV. For pharmacotherapy, see the Plan’s applicable pharmacy policies available at www.bmchp.org for BMC HealthNet Plan members and posted at www.wellsense.org for Well Sense Health Plan members; pharmacy policies include prior authorization guidelines and medical necessity criteria for the Plan’s covered drug list (categorized by medical drug name), including but not limited to the Plan’s Egrifta® pharmacy policy, policy number 9.032.

It will be determined during the Plan’s prior authorization process if the procedure is considered medically necessary for the requested indication. See Plan policy, Medically Necessary (policy number OCA 3.14), for the product-specific definitions of medically necessary treatment. Review Plan policy, Cosmetic, Reconstructive, and Restorative Services (policy number OCA 3.69), for the product-specific definitions of cosmetic services, cosmetic surgery, and/or reconstructive surgery and procedures. Refer to the following Plan policies for information regarding additional breast procedures: Breast Reconstruction (policy number OCA 3.43), Breast Reduction Mammoplasty (policy number OCA 3.44), and Gynecomastia Surgery (policy number OCA 3.48). The Plan will review requests for breast reconstruction procedures for gender reassignment, including augmentation for male-to-female (MtF) members and mastectomy for female-to-male (FtM) members, using the medical criteria included in the Gender Reassignment Surgery medical policy, policy number OCA 3.11 (rather than other Plan medical policies related to the requested breast procedures).

Description of Item or Service Mastopexy: Also known as a breast lift, this is a surgical procedure designed to lift or change the shape of a person’s breast. Mastopexy may involve lifting the breast tissue, repositioning the areola or nipple, and removing skin.

Medical Policy Statement Mastopexy or breast lift surgery is considered to be medically necessary when the following applicable criteria are met and documented in the member’s medical record (including preoperative photographs, which will be submitted as part of the prior authorization review process if requested by the Plan), as specified below in item 1 or item 2:

1. Mastopexy as Part of Breast Reconstruction Related to Breast Cancer Treatment:

Mastopexy

BOTH of the following applicable criteria must be met, as specified below in item a and item b:

a. The mastopexy will be performed on the affected breast and/or unaffected contralateral breast to create symmetry in a member who has undergone at least ONE (1) of the following therapies/procedures, as specified below in items (1) through (4):

(1) Breast conservation therapy (BCT); OR

(2) Lumpectomy; OR

(3) Mastectomy; OR

(4) Other diagnostic procedures causing deformity of the breast in connection with breast cancer, evaluation of breast cancer or suspected breast cancer, or to prevent development of breast cancer in high risk patients; AND

b. Member has had a mammogram within 12 calendar months of the date of the planned mastopexy that was negative for cancer, including mammography on the unaffected side if mastopexy will be done on the unaffected breast to create symmetry after breast surgery related to breast cancer (unless oncoplastic mastopexy is performed concurrently with the breast surgery related to breast cancer treatment and then the criterion requiring a mammogram negative for cancer would not be applicable); OR

2. Mastopexy to Treat Another Medical Condition:

BOTH of the following applicable criteria must be met when mastopexy is used to treat a medical condition other than breast reconstruction related to breast cancer treatment, as specified below in item a and item b:

a. The member has at least ONE (1) of the following conditions, as specified below in items (1) through (4):

(1) Breast agenesis; OR

(2) Medically refractory inframammary hidradenitis; OR

(3) Poland’s syndrome; OR

(4) Pre-menarchal breast bud injury; AND

b. If the member is 40 years of age or older, the member has had a mammogram within 12 calendar months from the date of the mastopexy that was negative for cancer in both breasts. Mastopexy

See Plan policies Breast Reconstruction (policy number OCA 3.43) and Breast Reduction Mammoplasty (policy number OCA 3.44) for medical guidelines and applicable coding for additional procedures related to breast reconstruction after mastectomy or lumpectomy. Review the Gynecomastia Surgery medical policy (policy number OCA 3.48) for medical necessity criteria for gynecomastia surgery (including but not limited to the surgical treatment for gynecomastia to reduce HIV-associated lipohypertrophy of the chest). See the Plan medical policy, Cosmetic, Reconstructive, and Restorative Services (policy number OCA 3.69), rather than this policy for medical necessity criteria for the following indications for treatments: Treatment of HIV-associated lipodystrophy when it is not associated with gynecomastia surgery (e.g., liposuction/suction assisted lipectomy, autologous fat grafts, reconstructive breast procedures, and/or dermal filler injections for the treatment of facial lipoatrophy syndrome) and/or the treatment of lipodystrophy when the condition is not associated with HIV. For pharmacotherapy, see the Plan’s applicable pharmacy policies available at www.bmchp.org for BMC HealthNet Plan members and posted at www.wellsense.org for Well Sense Health Plan members; pharmacy policies include prior authorization guidelines and medical necessity criteria for the Plan’s covered drug list (categorized by medical drug name), including but not limited to the Plan’s Egrifta® pharmacy policy, policy number 9.032.

Limitations Mastopexy is considered a cosmetic service when Plan criteria specified in this policy are not met.

Definitions Cosmetic Services: Those services that are performed for the primary purpose of altering or improving physical appearance and that do not constitute reconstructive and restorative services as defined below. Services that meet the definition of reconstructive and restorative services are not considered cosmetic. See Plan policy, Cosmetic, Reconstructive, and Restorative Services (policy number OCA 3.69), for the product-specific definitions of cosmetic services.

Hidradenitis Suppurativa (HS): A rare chronic skin condition involving the apocrine sweat glands, which are found predominantly in the axilla and inguinoperineal regions, but have been described at other sites, including the inframammary fold. In its earliest stage, HS often looks like boils, pimples, or lesions. Unlike everyday pimples, HS forms in areas where skin touches skin. Without treatment, HS can worsen and the individual may develop painful breakouts that rupture and leak a foul-smelling fluid (which heal and then reappear), scars that become thicker with time, skin that begins to look spongy as tunnel-like tracts form deep in the skin, serious infections, and skin cancer (rare). Treatment may include complex surgical intervention with wide excision of involved tissue. Inframammary hidradenitis tends to affect young women (but can affect individuals from puberty to middle age) and can prove resistant even to this radical form of surgery, which often results in marked scarring and breast deformity. The wide excision of inframammary skin used in a reduction mastopexy procedure improves, cosmesis, reduces the depth of the inframammary fold, and makes hygiene easier in the long term.

Mastopexy

HIV-associated Lipodystrophy: Abnormal fat accumulation (lipohypertrophy), localized loss of fat tissue (lipoatrophy), or a combination of both that are associated with metabolic complications (such as dyslipidemia, glucose intolerance, and insulin resistance) and contribute to HIV-related morbidity and mortality through increased cardiovascular and cerebrovascular disease risk. The syndrome occurs in HIV-infected patients treated with antiretroviral medications (e.g., protease inhibitors and nucleoside reverse transcriptase inhibitors). HIV may be a causal factor for lipodystrophy by interfering with way the body processes adipose tissue. Treatment for HIV-associated lipodystrophy may include conservative treatment (diet modification and exercise), pharmacotherapy, or surgical intervention when conservative treatment and drug therapy are not effective. The magnitude of fat loss determines the severity of metabolic complications and associated treatment plan.

Lipodystrophy: A medical condition resulting in abnormal fat accumulation (lipohypertrophy), localized loss of fat tissue (lipoatrophy), or a combination of both with metabolic complications (such as dyslipidemia, glucose intolerance, and insulin resistance). With lipoatrophy, there is selective, subcutaneous fat loss (either partial or near total absence of adipose tissue) from various regions of the body, generally occurring in the limbs, face, and/or buttocks. Lipohypertrophy (fat accumulation), when present, most commonly occurs in the abdomen, dorsocervical area (developing fat pad enlargement known as buffalo hump), and the breast/chest. In addition, lipomas may develop in other parts of the body. A disruption in the total amount and distribution of adipose tissue (as an active endocrine organ) contribute to metabolic abnormalities that alter hormone levels secreted by adipose tissue. The magnitude of fat loss determines the severity of metabolic complications and may result in dyslipidemia and abnormal glucose metabolism (predisposing the patient to cardiovascular disease and diabetes mellitus). The physical changes associated with the lipodystrophy syndrome can be divided into three (3) major types: lipoatrophy or fat wasting; lipohypertrophy or fat accumulation; and mixed forms with atrophy and hypertrophy coexisting in different body regions. Men tend to experience lipoatrophy and women are more likely to have lipohypertrophy. Withdrawal of antiretroviral therapy and therapeutic strategies do not achieve substantial improvements and may not be medically appropriate. Two major types of lipodystrophies are inherited (familial or genetic lipodystrophies) or secondary to a medical condition or drug treatment (e.g., HIV-associated lipodystrophy).

Oncoplastic Breast Reconstruction: The surgical management of breast cancer with complete resection of the tumor, preservation of normal tissue, immediate breast reconstruction of the affected breast at the time of the surgical treatment for breast cancer, and may also include symmetrizing surgery for the contralateral breast to improve aesthetic outcomes and patient satisfaction.

Poland’s Syndrome: A rare congenital abnormality characterized by absence (aplasia) of chest wall muscles on one side of the body (absence of the sternocostal portion of the pectoralis major), hypoplasia of the hand and forearm, and complete or incomplete syndactyly and short fingers. Affected individuals may have variable associated features, such as under development or absence of one nipple (including the darkened area around the areola) and/or patchy absence of hair under the axilla. In females (including individuals born with female reproductive organs and/or with typical female karyotype with two [2] X chromosomes), there may be underdevelopment or absence (aplasia) Mastopexy

of one breast and subcutaneous tissues. In some cases, associated skeletal abnormalities may also be present, such as underdevelopment or absence of upper ribs, elevation of the shoulder blade (Sprengel deformity), and/or shortening of the arm with underdevelopment of the ulna and radius.

Reconstructive and Restorative: (a) Those services that are performed for the primary purpose of improving, repairing, restoring, or correcting a physical functional impairment, or relieving pain, resulting from any of the following: accidental traumatic injury, post-therapeutic intervention (e.g., radiation or chemotherapy), birth abnormality, congenital defect, disease process, or anatomic variants; or (b) post-mastectomy services for eligible members. See Plan policy, Cosmetic, Reconstructive, and Restorative Services (policy number OCA: 3.69), for the product-specific definitions of reconstructive and restorative services.

Applicable Coding The Plan uses and adopts up-to-date Current Procedural Terminology (CPT) codes from the American Medical Association (AMA), International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) diagnosis codes developed by the World Health Organization and adapted in the United Stated by the National Center for Health Statistics (NCHS) of the Centers for Disease Control under the U.S. Department of Health and Human Services, and the Health Care Common Procedure Coding System (HCPCS) established and maintained by the Centers for Medicare & Medicaid Services (CMS). Because the AMA, NCHS, and CMS may update codes more frequently or at different intervals than Plan policy updates, the list of applicable codes included in this Plan policy is for informational purposes only, may not be all inclusive, and is subject to change without prior notification. Whether a code is listed in the Applicable Coding section of this Plan policy does not constitute or imply member coverage or provider reimbursement. Providers are responsible for reporting all services using the most up-to-date industry-standard procedure and diagnosis codes as published by the AMA, NCHS, and CMS at the time of the service.

Providers are responsible for obtaining prior authorization for the services specified in the Medical Policy Statement section and Limitation section of this Plan policy, even if an applicable code appropriately describing the service that is the subject of this Plan policy is not included in the Applicable Coding section of this Plan policy. Coverage for services is subject to benefit eligibility under the member’s benefit plan. Please refer to the member’s benefits document in effect at the time of the service to determine coverage or non-coverage as it applies to an individual member. See Plan reimbursement policies for Plan billing guidelines.

CPT Code Description: Code Covered When Medically Necessary 19316 Mastopexy

Mastopexy

Clinical Background Information In most instances, mastopexy is performed primarily for aesthetic and cosmetic reasons; the main exception to this is in post-mastectomy reconstruction. Generally, mastopexy is performed in the outpatient setting under general anesthesia, with surgery lasting between one (1) to three (3) hours.

There are several types of mastopexy or breast lift procedures. The full breast lift is the most invasive type of surgery and involves an anchor incision or inverted T along the fold underneath the breast, incisions around areola, and a vertical incision between the areola and the base of the breast. This method is widely used because it produces the desired shape and position of the breast on the chest wall. In this technique, excess skin is removed, the breast is elevated, and frequently the size of the areola is reduced; this allows maximal change to the breast.

Modified or limited breast lifts use less incisions, leaving fewer scars. The potential drawback is that there can be less change made to the shape of the breast. One form of the modified breast lift is the Benelli breast lift or the concentric mastopexy or donut lift. During concentric mastopexy, circular incisions are made around the areola. The skin between the two incisions (shaped something like a doughnut) is removed, the nipple and areola are usually moved upward, and the surrounding skin is stitched to the skin around the areola. Because there is a relatively small amount of skin removal, this technique will only work for women (including individuals born with female reproductive organs and/or with typical female karyotype with two [2] X chromosomes) with smaller breasts and minimal sagging. The vertical mastopexy uses a similar technique, extending the incision vertically below the areola to the breast crease by the chest. This approach allows an additional strip of skin to be removed, giving the surgeon the option of greater correction.

At the time of the Plan’s most recent policy review, the following applicable clinical guidelines were found from the Centers for Medicare & Medicaid Services (CMS) for breast surgery: National Coverage Determination (NCD) for Breast Reconstruction Following Mastectomy (140.2), NCD for Mammograms (220.4), Local Coverage Determination (LCD) for Cosmetic and Reconstructive Surgery (L34698), and LCD for Reduction Mammaplasty (L35001). No CMS clinical guidelines were identified specifically for mastopexy surgery during the policy review process. CMS guidelines for the medically necessary treatment of lipodystrophy only include dermal injections for the treatment of facial lipodystrophy syndrome (LDS) using FDA-approved dermal fillers with HIV infected beneficiaries when facial LDS caused by antiretroviral HIV treatment is a significant contributor to the patient’s depression. Verify if applicable CMS criteria are in effect for the requested breast procedure in an NCD or LCD on the date of the prior authorization request for a Senior Care Options member.

References American Academy of Dermatology (AAD). Hidradenitis suppurativa: Signs and symptoms. Accessed at: http://www.aad.org/dermatology-a-to-z/diseases-and-treatments/e---h/hidradenitis- suppurativa/signs-and-symptoms

Mastopexy

American Cancer Society (ACS). American Cancer Society recommendations for early breast cancer detection in women without breast symptoms. Last Revised 10/20/15. Accessed at: http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breastcancer-early-detection-acs-recs

The American College of Obstetricians and Gynecologists (ACOG). ACOG Statement on Revised American Cancer Society Recommendations on Breast Cancer Screening. October 20, 2015. Accessed at: http://www.acog.org/About-ACOG/News-Room/Statements/2015/ACOG-Statement-on- Recommendations-on-Breast-Cancer-Screening

American Society of Clinical Oncology (ASCO). Khatcheressian JL, Hurley P, Bantug E, Esserman LJ, Grunfeld E, Halberg F, Hantel A, Henry NL, Muss HB, Smith TJ, Vogel VG, Wolff AC, Somerfield MR, Davidson NE. Breast Cancer Follow-Up and Management After Primary Treatment: American Society of Clinical Oncology Clinical Practice Guideline Update. Journal of Clinical Oncology, Vol 3, Issue 7 (March), 2013: 961-965.

American Society of Plastic Surgeons. Breast Lift Surgery. Mastopexy. Accessed at: http://www.plasticsurgery.org/Patients_and_Consumers/Procedures/Cosmetic_Procedures/Breast_Lif t.html

Beale EW, Ramanadham S, Harrison Bridget, Rasko Y, Armijo B, Rohrich RJ. Achieving Predictability in Augmentation Mastopexy. Plastic & Reconstructive Surgery: March 2014 - Volume 133 - Issue 3 - p 284e–292e. doi: 10.1097/PRS.0000000000000079.

Centers for Medicare & Medicaid Services (CMS). Decision Memo for Dermal injections for the treatment of facial lipodystrophy syndrome (FLS) (CAG-00412N). March 23, 2010. Accessed at: https://www.cms.gov/medicare-coverage-database/details/nca-decision- memo.aspx?&NcaName=Dermal%20injections%20for%20the%20treatment%20of%20facial%20lipodys trophy%20syndrome%20(FLS)&ExpandComments=n&fromdb=true&bc=AAAAAAAAACAAAA&NCAId=2 34&ver=5&

Centers for Medicare & Medicaid Services (CMS). Local Coverage Determination (LCD) for Cosmetic and Reconstructive Surgery (L34698). Contractor Name: Wisconsin Physicians Service Insurance

Corporation. Accessed at: https://www.cms.gov/medicare-coverage-database/overview-and-quick- search.aspx

Centers for Medicare & Medicaid Services (CMS). Local Coverage Determination (LCD) for Reduction Mammaplasty (L35001). Contractor Name: National Government Services, Inc. Accessed at: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Breast Reconstruction Following Mastectomy (140.2). Version Number 1. Effective Date 01/01/97. Accessed

Mastopexy

at: https://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?NCDId=64&ncdver=1&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=Mas sachusetts&CptHcpcsCode=19318&bc=gAAAABAAAAAAAA%3d%3d&

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Mammograms (220.4). Version Number 1. Effective Date 05/15/78. Accessed at: https://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?NCDId=186&ncdver=1&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=M assachusetts&CptHcpcsCode=19318&bc=gAAAABAAAAAAAA%3d%3d&

Centers for Medicare & Medicaid Services (CMS). Welcome to the Medicare Coverage Database. Accessed at: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx

Florenza CG, Chou SH, Mantzoros CS. Lipodystrophy: pathophysiology and advances in treatment. Nat Rev Endocrinol. 2011 Mar;7(3):137-50. doi: 10.1038/nrendo.2010.199. Epub 2010 Nov 16. PMID: 21079616. Accessed at: https://www.ncbi.nlm.nih.gov/pubmed/21079616

Foundation for Healthy Communities. N.H. Prevention Guidelines. Effective January 1, 2015 – December 31, 2016. Accessed at: http://www.healthynh.com/images/PDFfiles/publications/Prevention_11x17Guidelines_2015- 2016.pdf

Garg A. The Physician’s Guide to Lipodystrophy Disorders. National Organization for Rare Disorders (NORD). 2012. Accessed at: http://nordphysicianguides.org/wp- content/uploads/2012/11/NORD_Physician_Guides_Lipodystrophies.pdf

Gervasoni C, Ridolfo A, Rovati L, Vaccarezza M, Carsana L, Galli M. Maintenance of breast size reduction after mastoplasty and switch to a protease inhibitor-sparing regimen in an HIV-positive woman with highly active antiretroviral therapy-associated massive breast enlargement. AIDS Patient Care STDS 2002;16(7):307. PMID: 12194727. Accessed at: https://www.ncbi.nlm.nih.gov/pubmed/12194727

Glesby MJ. Treatment of HIV-associated lipodystrophy. UpToDate®. Updated October 6, 2015. Literature Review March 2017. Accessed at: http://www.uptodate.com/contents/treatment-of-hiv- associated-lipodystrophy

Hammond DC, Alfonso D, Khuthaila DK. Mastopexy using the short scar periareolar inferior pedicle reduction technique. Plast Reconstr Surg. 2008 May;121(5):1533-9. doi: 10.1097/PRS.0b013e31816c3b0b.. PMID: 18453975. Accessed at: https://www.ncbi.nlm.nih.gov/pubmed/18453975

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Jansen DA, Spencer Stoetzel R, Leveque JE. Premenarchal athletic injury to the breast bud as the cause for asymmetry: prevention and treatment. Breast J. 2002 Mar-Apr;8(2):108-11. PMID: 11896757. Accessed at: https://www.ncbi.nlm.nih.gov/pubmed/11896757

Lickstein D. Breast lift (mastopexy) – series - Incisions. MedLine Plus. U.S. National Library of Medicine and National Institutes of Health. February 12, 2013. Accessed at: http://www.nlm.nih.gov/medlineplus/ency/presentations/100188_1.htm

Lind DS, Smith BL, Souba WW. Breast Procedures. ASC Surgery: Principles & Practice. Medscape. April 18, 2005. Accessed at: http://www.medscape.com/viewarticle/503006

Liu Y, Eisen DB. Treatment of Hidradenitis Suppurativa: What’s New? Cosmetic Dermatology® May 2011. Vol. 24 No. 5.

Massachusetts Executive Office of Health and Human Services (EOHHS). MassHealth Guidelines for Medical Necessity Determination for Breast Reconstruction. Accessed at: http://www.mass.gov/eohhs/docs/masshealth/guidelines/mg-breastreconstruction.pdf

National Comprehensive Cancer Network (NCCN). NCCN Categories of Evidence and Consensus. Accessed at: http://www.nccn.org/

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Breast Cancer. Version 1. 2017 – March 10, 2017. Accessed at: http://www.nccn.org/

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Breast Cancer Risk Reduction. Version 1.2017 – December 16, 2016. Accessed at: http://www.nccn.org/

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Breast Cancer Screening and Diagnosis. Version 1.2016 – July 27, 2016. Accessed at: http://www.nccn.org/

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Genetic/Familial High-Risk Assessment: Breast and Ovarian. Versions 2.2017 – December 7, 2016. Accessed at: Accessed at: http://www.nccn.org/

Omozehio Iwuala S, Lesi OA, Adetola Fasanmade O, Sabir AA, Adeyemi Olamoyegun M, Okany CC. Prevalence of and Risk Factors for Lipoatrophy in Patients with HIV Infection in Nigeria. AIDS Research and Treatment. Volume 2015. 2015. Article ID 402638. Accessed at: https://www.hindawi.com/journals/art/2015/402638/

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Rancati A, Gonzalez E, Dorr J, Angrigiani C. Oncoplastic surgery in the treatment of breast cancer. Ecancermedicalscience. 2013; 7: 293. Published online 2013 Feb 21. doi: 10.3332/ecancer.2013.293. PMCID: PMC3575202. Accessed at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3575202/

Robles DT. Lipodystrophy in HIV. Medscape. September 19, 2016. Accessed at: http://emedicine.medscape.com/article/1082199-overview

Rohrich RJ, Thornton JF, Jakubietz RG, Jakubietz MG, Grünert JG. The limited scar mastopexy: current concepts and approaches to correct breast ptosis. Plast Reconstr Surg. 2004 Nov;114(6):1622-30. Accessed at: https://www.ncbi.nlm.nih.gov/pubmed/15509961

Shiffman, M. (Ed.) Mastopexy and Breast Reduction: Principles and Practice. Springer 2009. Accessed at: http://books.google.com/books?id=CRzbklu1FFEC&pg=PA39&lpg=PA39&dq=mammogram+before+ma stopexy&source=bl&ots=drK8AJd7Hh&sig=8mH2refr8FF8J9d03Gi3ft0Qbn0&hl=en&sa=X&ei=ad5ZUZP bN6bF0gHU84CADw&ved=0CBsQ6AEwAQ#v=onepage&q=mammogram%20before%20mastopexy&f=f alse

Spear SL, Pelletiere CV, Lee ES, Grotting JC. Anterior thoracic hypoplasia: a separate entity from Poland syndrome. Plast Reconstr Surg. 2004 Jan;113(1):69-77; discussion 78-9. PMID: 14707624. doi: 10.1097/01.PRS.0000090727.07735.F5. Accessed at: https://www.ncbi.nlm.nih.gov/pubmed/14707624

Stevens WG, Freeman ME, Stoker DA, Quardt SM, Cohen R, Hirsch EM. One-stage mastopexy with breast augmentation: a review of 321 patients. Plast Reconstr Surg. 2007 Nov;120(6):1674-9.

Torre J. Breast Mastopexy. Medscape. Drugs, Diseases. Clinical Procedures. February 23, 2016. Accessed at: http://emedicine.medscape.com/article/1273551-overview

U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2016 Feb 16;164(4):279-96. Accessed at: http://www.guideline.gov/content.aspx?f=rss&id=50033&osrc=12

Williams EV, Drew PJ, Douglas-Jones AG, Mansel RE. Combined wide excision and mastopexy/reduction mammoplasty for inframammary hidradenitis: a novel and effective approach. Breast. 2001 Oct;10(5):427-31. PMID: 14965619. DOI: 10.1054/brst.2000.0271. Accessed at: http://www.ncbi.nlm.nih.gov/pubmed/14965619

Original Effective Original Approval Original Policy Date* and Version Policy Owner Date Approved by Number

Mastopexy

Regulatory Approval: N/A 10/01/09 Medical Policy Manager MPCTAC, Utilization Version 1 as Chair of Medical Policy, Management Committee Internal Approval: Criteria, and Technology (UMC), and Quality 05/26/09: MPCTAC Assessment Committee Improvement Committee 05/26/09: UMC (MPCTAC) (QIC) 07/22/09: QIC *Effective Date for the BMC HealthNet Plan Commercial Product(s): 01/01/12 *Effective Date for the Well Sense Health Plan New Hampshire Medicaid Product(s): 01/01/13 *Effective Date for the Senior Care Options Product(s): 01/01/16

Policy Revisions History Revision Effective Date Review Date Summary of Revisions Approved by and Version Number 04/01/10 No changes. Version2 04/27/10: MPCTAC 05/26/10: QIC 04/01/11 No changes to codes or criteria. Version 3 04/20/11: MPCTAC Updated references. 05/25/11: QIC

04/01/12 Updated criteria to include provisions Version 4 04/18/12: MPCTAC of Women’s Health and Cancer Right’s 06/27/12: QIC Act of 1998. 07/30/12 Off cycle review for Well Sense Health Version 5 08/03/12: MPCTAC Plan. Revised Summary statement. 09/05/12: QIC Updated references. 04/01/13 Review for effective date of 08/01/13. 08/01/13 04/17/13: MPCTAC Added references. Revised Summary, Version 6 05/16/13: QIC Limitations, and Clinical Background Information sections, added criterion in Medical Policy Statement section. Referenced the following Plan policies: Medically Necessary, Breast Reconstruction, Gynecomastia Surgery, and Cosmetic, Reconstructive, and Restorative Services. Revised language of introductory paragraph of Applicable Coding section. Deleted product- specific definitions. 06/01/13 Review for effective date of 09/01/13. 09/01/13 06/19/13: MPCTAC Added note to Medical Policy Version 7 07/18/13: QIC Statement section and updated Definitions section. 04/01/14 Review for effective date 08/01/14. 08/01/14 04/16/14: MPCTAC Reformatted and revised the Medical Version 8 05/14/14: QIC Mastopexy

Policy Revisions History Policy Statement section, including revised requirements for mammograms before mastopexy. Revised Definitions and References sections. 04/01/15 Review for effective date 06/01/15. 06/01/15 04/15/15: MPCTAC Removed Commonwealth Care, Version 9 05/13/15: QIC Commonwealth Choice, and Employer Choice from the list of applicable products because the products are no longer available. Updated Summary section. Made administrative changes to the Medical Policy Statement section and stated that preoperative photographs may be required upon request during the Plan prior authorization process. 11/25/15 Review for effective date 01/01/16. 01/01/16 11/18/15: MPCTAC Updated template with list of Version 10 11/25/15: MPCTAC applicable products and notes. (electronic vote) Revised language in the Applicable 12/09/15: QIC Coding section. 04/01/16 Review for effective date 06/01/16. 06/01/16 04/20/16: MPCTAC Revised the Clinical Background Version 11 05/23/16: QIC Information, References, and Reference to Applicable Laws and Regulations sections. 09/28/16 Review for effective date 11/01/16. 11/01/16 09/30/16: MPCTAC Administrative changes made to clarify Version 12 (electronic vote) language related to gender. 10/12/16: QIC 04/01/17 Review for effective date 05/08/17. 05/08/17 04/19/17: MPCTAC Administrative changes made to the Version 13 Medical Policy Statement section. Updated Summary, Definitions, Clinical Background Information, References, and References to Applicable Laws and Regulations sections.

Last Review Date 04/01/17

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Next Review Date 04/01/18

Authorizing Entity MPCTAC

Other Applicable Policies Medical Policy - Breast Reconstruction, policy number OCA 3.43 Medical Policy - Breast Reduction Mammoplasty, policy number OCA 3.44 Medical Policy - Cosmetic, Reconstructive, and Restorative Services, policy number OCA 3.69 Medical Policy - Gender Reassignment Surgery, policy number OCA 3.11 Medical Policy - Gynecomastia Surgery, policy number OCA 3.48 Medical Policy - Medically Necessary, policy number OCA 3.14 Pharmacy Policy - Egrifta®, policy number 9.032 Reimbursement Policy - Anesthesia, policy number 4.103 Reimbursement Policy - Bilateral and Multiple Procedure Reductions, policy number 4.607 Reimbursement Policy - Free Standing Surgical Facility Services, policy number 4.114 Reimbursement Policy - General Billing and Coding Guidelines, policy number 4.31 Reimbursement Policy - General Billing and Coding Guidelines, policy number WS 4.17 Reimbursement Policy - General Clinical Editing and Payment Accuracy Review Guidelines, policy number 4.108 Reimbursement Policy - General Clinical Editing and Payment Accuracy Review Guidelines, policy number WS 4.18 Reimbursement Policy - Outpatient Hospital, policy number 4.17 Reimbursement Policy - Physician and Non Physician Practitioner Services, policy number 4.608 Reimbursement Policy - Physician and Non Physician Practitioner Services, policy number WS 4.28 Reimbursement Policy - Professional Bilateral and Multiple Procedure Reductions, policy number: WS 4.24

Reference to Applicable Laws and Regulations 78 FR 48164-69. Centers for Medicare & Medicaid Services (CMS). Medicare Program. Revised Process for Making National Coverage Determinations. August 7, 2013. Accessed at: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/FR08072013.pdf

130 CMR 410.00. Division of Medical Assistance. Outpatient Hospital Services. MA Reg. #1280. February 13, 2015. Accessed at: http://www.mass.gov/courts/docs/lawlib/116- 130cmr/130cmr415.pdf

130 CMR 433.00. Division of Medical Assistance. Physician Services. MA Reg. #1280. February 13, 2015. Accessed at: http://www.mass.gov/courts/docs/lawlib/116-130cmr/130cmr433.pdf Mastopexy

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15. Covered Medical and Other Health Services. Rev. 212. 11/06/15. Accessed at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf

The Commonwealth of Massachusetts. Division of Insurance. Bulletin 2016-14; HIV Associated Lipodystrophy Syndrome Medical Benefit Requirements; Issued 11/8/16. Accessed at: http://www.mass.gov/ocabr/insurance/providers-and-producers/doi-regulatory-info/doi-regulatory- bulletins/2016-doi-bulletins/bulletin-2016-14.html

The Commonwealth of Massachusetts. Massachusetts General Laws Mandating that Certain Health Benefits Be Provided By Commercial Insurers, Blue Cross and Blue Shield and Health Maintenance Organizations. Regulatory Citations. May 31, 2016. Accessed at: http://www.mass.gov/ocabr/docs/doi/consumer/healthlists/mndatben.pdf

The Commonwealth of Massachusetts. MassHealth Provider Manual Series. Physician Manual. Transmittal Letter PHY-140. January 1, 2014. Accessed at: http://www.mass.gov/eohhs/docs/masshealth/regs-provider/regs-physician.pdf

M.G.L. Chapter 233: An Act Relative to HIV-Associated Lipodystrophy Syndrome Treatment.

NH RSA 417-D:2-b. New Hampshire Title XXXVII Insurance. Chapter 417-D Women’s Health Care. Section 417-D:2-b Reconstructive Surgery. Accessed at: http://www.gencourt.state.nh.us/rsa/html/xxxvii/417-D/417-D-mrg.htm

Title XI Women's Health and Cancer Act. H.R. 4328 Omnibus Appropriations Bill FY99 Conference Report 105-825. Public Law 105-277. October 21, 1998.

U.S. Women's Health and Cancer Right Act of 1998.

Disclaimer Information: + Medical Policies are the Plan’s guidelines for determining the medical necessity of certain services or supplies for purposes of determining coverage. These Policies may also describe when a service or supply is considered experimental or investigational, or cosmetic. In making coverage decisions, the Plan uses these guidelines and other Plan Policies, as well as the Member’s benefit document, and when appropriate, coordinates with the Member’s health care Providers to consider the individual Member’s health care needs. Plan Policies are developed in accordance with applicable state and federal laws and regulations, and accrediting organization standards (including NCQA). Medical Policies are also developed, as appropriate, with consideration of the medical necessity definitions in various Plan products, review of current literature, consultation with practicing Providers in the Plan’s service area who are medical experts in the particular field, and adherence to FDA and other government agency policies. Applicable state or federal mandates, as well as the Member’s benefit document, take precedence over these guidelines. Policies are reviewed and updated on an annual basis, or more frequently as needed. Treating providers are solely responsible for the medical advice and treatment of Members.

Mastopexy

The use of this Policy is neither a guarantee of payment nor a final prediction of how a specific claim(s) will be adjudicated. Reimbursement is based on many factors, including member eligibility and benefits on the date of service; medical necessity; utilization management guidelines (when applicable); coordination of benefits; adherence with applicable Plan policies and procedures; clinical coding criteria; claim editing logic; and the applicable Plan – Provider agreement.

Mastopexy