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 removal, breast reconstruction and revision following surgery for breast cancer, male gynecomastia, mastectomy for intractable breast pain and reduction mammoplasty.

Medical policy

• Breast Related Procedures - 91545
• Prophylactic Cancer Risk Reduction Surgery - 91508

Breast surgeries coverage

For commercial group and individual plans, and for 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 may be covered at a different cost-sharing level than our standard benefit coverage levels.

To verify member cost sharing and coverage, 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
• Reduction mammoplasty, male or female

Participating providers: Use our online authorizations tool to go to GuidingCare. 

Non-participating providers: Use this Medical Authorization form.

Breast surgeries billing

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