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: 08/06/2015
Policy Effective Date: 10/06/2015
Provider Tool Effective Date: 12/12/2015
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:
Service Requested (CPT if known):
Place of Service:
Outpatient
Home
Inpatient
Other:
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.
Please check all that apply to the individual:
Reconstructive Breast Surgery
Request is for Reconstructive Breast Surgery related to breast cancer treatment
Individual has had a mastectomy, lumpectomy or other breast surgery to treat breast cancer
Procedure is to rebuild the normal contour of the affected breast to produce a more normal
appearance
(If checked, please mark all of the following that apply)
Procedure is for reconstructive surgery
Procedure is an implant insertion
Procedure involves the individual’s muscle tissue being transposed from another site
Procedure is a revision of pre-existing breast implants placed for cosmetic purposes
Procedure is a removal of pre-existing breast implants placed for cosmetic purposes
Procedure is to rebuild the normal contour of the contralateral unaffected breast to produce a
more normal appearance
(If checked, please mark all that apply)
Procedure is a reduction mammaplasty
Procedure is an augmentation mammaplasty with implants
Procedure is a mastopexy
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: 08/06/2015
Policy Effective Date: 10/06/2015
Provider Tool Effective Date: 12/12/2015
Request is for surgery to reconstruct both breasts following bilateral mastectomy
Request is for reconstructive Breast Surgery not related to treatment of breast cancer
The procedure is to alter the contour of the breast of an individual with significant (nonmalignant) abnormalities related to prior mastectomy or lumpectomy
The procedure is to alter the contour of the breast of an individual with significant (nonmalignant) abnormalities related to trauma
The procedure is to alter the contour of the breast of an individual with significant (nonmalignant) abnormalities related to infection
The procedure is to alter the contour of the breast of an individual with significant (nonmalignant) abnormalities related to other non-malignant disease
The procedure is to alter the contour of the breast of an individual with significant (nonmalignant) abnormalities related to congenital defect: Poland’s syndrome :
(If checked, please mark all that apply to the individual)
Congenital absence or hypoplasia of pectoralis major and minor muscles
Breast hypoplasia
Congenital partial absence of the upper costal cartilage
The procedure is to alter the contour of the breast of an individual with significant (nonmalignant) abnormalities related to other congenital defects not specified above.
Please specify: _______________________
Management of Breast Implants
Request is for surgery to remove a breast implant
The procedure is to remove a partially or completely filled Silicone Gel implant due to
documented rupture of implant on imaging (mammography, ultrasound, or MRI)
The procedure is to remove a Silicone Gel filled implant
(If checked, mark all that apply to the individual)
due to infection of implant or surrounding tissue
due to implant exposure/extrusion
due to pain related to Baker Class IV capsular contracture
prior to surgical treatment of breast cancer
The procedure is to remove a silicone gel filled implant with or without reimplantation
when the individual has a history of mastectomy, lumpectomy or treatment of breast cancer
and received the original implant for reconstructive purposes and has developed a visible
distortion (Baker Class III contracture).
The procedure is to remove a Saline filled or “Alternative” breast implant implant
(If checked, mark all that apply to the individual)
due to infection of implant or surrounding tissue
due to implant exposure/extrusion
due to pain related to Baker Class IV capsular contracture
prior to surgical treatment of breast cancer
The procedure is to remove a ruptured saline-filled or “alternative” implant with or without
reimplantation when the individual has a history of mastectomy, lumpectomy or treatment
of breast cancer and received the original implant for reconstructive purposes
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: 08/06/2015
Policy Effective Date: 10/06/2015
Provider Tool Effective Date: 12/12/2015
The procedure is to remove a saline-filled or “alternative” implant with or without
reimplantation when the individual has a history of mastectomy, lumpectomy or treatment
of breast cancer and received the original implant for reconstructive purposes and has
developed a visible distortion (Baker Class III contracture)
The procedure is for removal of a ruptured saline-filled implant when the individual does not
have a history of breast reconstruction following mastectomy, lumpectomy or breast cancer
treatment
The procedure is for removal of a ruptured “Alternative” implant when the individual does
not have a history of breast reconstruction following mastectomy, lumpectomy or breast
cancer treatment
The procedure is for removal of ANY type of breast implant due to systemic symptoms
attributed to connective tissue disease
The procedure is for removal of ANY type of breast implant due to systemic symptoms
attributed to autoimmune diseases
The procedure is for removal of ANY type of breast implant due to the individual’s anxiety
The procedure is for removal of ANY type of breast implant due to pain not related to
contractures or rupture
The procedure is for reimplantation of a breast implant that was initially inserted for cosmetic
purposes only and was subsequently removed as part of a medically necessary surgery
The procedure is for reimplantation of a breast implant that was initially inserted for cosmetic
purposes only and was subsequently removed as part of a reconstructive surgery
Request is for surgery on the contralateral breast to produce a symmetrical appearance after
implant removal with reimplantation
The original implant was placed for reconstructive purposes in an individual with a history of
mastectomy, lumpectomy, or treatment of breast cancer
Request is for Augmentation mammoplasty which is not being done as part of a covered breast
reconstruction service
Request is for a Breast lift which is not being done as part of a covered breast reconstruction service
Request is for Implant repositioning which is not being done as part of a covered breast reconstruction
Service
Request is for Repair of inverted nipples which is not being done as part of a covered breast
reconstruction service
Request is for Mastopexy which is not being done as part of a covered breast reconstruction service
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: 08/06/2015
Policy Effective Date: 10/06/2015
Provider Tool Effective Date: 12/12/2015
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 Completing
Form and Attestation (Please Print)*
Date
*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.