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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.42 Diagnostic and Therapeutic Breast Procedures : 9.2.42.3 Breast Reconstruction

9.2.42.3
Breast reconstruction may be performed in a single stage or several stages. Breast reconstruction is a benefit when all of the following criteria are met:
Reconstruction to attain symmetry is required and may include a surgical procedure to the contralateral breast and may be either a reduction or an augmentation.
Procedure options for breast reconstruction following a mastectomy include, but are not limited to the following:
Documentation that supports medical necessity for breast reconstruction, including tattooing, must include the following:
All Medicaid services, including breast reconstruction after breast cancer surgery, are covered for Medicaid Breast and Cervical Cancer (MBCC) clients who are receiving active cancer treatment. “Active treatment” is defined as medical treatment following a cancer diagnosis that is intended to cure or otherwise treat a diagnosed cancer.
Active treatment may include some or all of the following:
Reconstructive surgery (e.g., breast reconstruction) is considered “active treatment” if it is intended to permanently correct a physical condition resulting from either the diagnosed cancer or the treatment of the diagnosed cancer.
Ongoing treatment of a persistent condition resulting from a diagnosed cancer or treatment of a diagnosed cancer is not considered “active treatment” if cancer is no longer present or in need of treatment.
The following breast reconstruction procedure codes may be reimbursed without prior authorization for services rendered to clients who are 18 years of age and older:
 
Prior authorization is required for services rendered to clients who are 17 years of age and younger or when the client does not meet gender or age criteria.
Procedure codes 11920, 11921, and 11922 may be reimbursed when performed as part of breast reconstruction.
Breast reconstruction claims denied for no history of previous mastectomy may be appealed with supporting documentation indicating the date of mastectomy, or the identified trauma, injury, or congenital or developmental abnormality.
9.2.42.3.1
Tattooing to correct color defects of the skin (procedure codes 11920, 11921, and 11922) are limited to two services per lifetime.
Tattooing claims denied for no history of breast reconstruction may be appealed with supporting documentation indicating the date of breast reconstruction, or the identified trauma, injury, or congenital or developmental abnormality.
9.2.42.3.2
The treatment of complications related to breast reconstruction may be reimbursed using procedure codes 19328, 19330, 19370, 19371, and 19380.
Procedure codes 19328, 19330, 19370, and 19371 may be reimbursed for services rendered to female clients only.
9.2.42.3.3
External breast prostheses are available through a durable medical equipment (DME) provider for a female client with a history of a medically necessary mastectomy procedure.
The following procedure codes may be reimbursed for external breast prostheses services rendered to female clients of any age:
 
To be considered for reimbursement, an LT or RT modifier must be appropriately appended to the submitted diagnostic and therapeutic breast procedure codes or external breast prostheses procedure codes.
The external breast prosthesis procedure codes are limited as follows:
 
Replacement of external breast prostheses may be considered at any time, through the prior authorization with documentation.
For a new or replacement external breast prosthesis procedure code outside the limitations, all of the following documentation must be submitted with the prior authorization request:
When requesting a prior authorization for procedure code L8035 (custom prosthesis), all of the following documentation must be submitted with the prior authorization request:
When requesting a prior authorization for procedure code L8039 (other prosthesis), all of the following documentation must be submitted with the prior authorization request:

Texas Medicaid & Healthcare Partnership
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