Breast surgeries

Applies to:

Commercial group HMO, EPO, POS and PPO plans

Commercial individual MyPriority® plans

Priority Health Choice plans (Medicaid and Healthy Michigan Plan)

Priority Health Medicare plans

Definition

Breast surgeries include breast implants explantation, breast MRIs, breast reconstruction and revision following surgery for breast cancer, male gynecomastia, mastectomy for intractable breast pain and reduction mammoplastyom.

Medical policy

Breast surgeries coverage

For commercial group and individual plans, and usually for employer group Medicare plans, breast surgeries are covered only when necessary due to functional impairment. See the criteria in the medical policy, above.

When these surgeries meet coverage criteria, they're covered at non-standard cost sharing.

Non-standard cost-sharing

If/when commercial employer group and MyPriority® individual plans cover certain surgeries, these surgeries are covered at a different cost-sharing level than our standard benefit coverage levels.

To verify member cost sharing, use the Member Inquiry tool and look in the Additional benefits drop-down menu for Certain surgeries benefit information.

Breast surgeries authorizations

Authorization is required for some diagnoses. Requirements vary by plan.

See the Authorization reference list for information on:

  • Breast MRI
  • Breast reconstruction & revision procedures
  • Breast-specific gamma imaging (BSGI)
  • Male gynecomastia
  • Prophylactic cancer risk-reduction surgery
  • Reduction mammoplasty

Participating providers use the Auth Request online authorization tool

Non-participating providers use the authorization forms.

Breast surgeries billing

See the medical policy for codes that may apply and codes not covered.