For Dates of Service Before January 1, 2020

Breast Reconstruction

Breast reconstruction requires PA; however, PA is waived for breast reconstruction when performed following a mastectomy for breast cancer and when the claim includes one of the following ICD diagnosis codes for breast cancer or a personal history of breast cancer. (Breast reconstruction is identified by CPT codes 19316–19325, 19340–19350, 19357–19369, 19380–19396.)

ICD Diagnosis Code Description
C50.011Malignant neoplasm of nipple and areola, right female breast
C50.012Malignant neoplasm of nipple and areola, left female breast
C50.111Malignant neoplasm of central portion of right female breast
C50.112Malignant neoplasm of central portion of left female breast
C50.211Malignant neoplasm of upper-inner quadrant of right female breast
C50.212Malignant neoplasm of upper-inner quadrant of left female breast
C50.311Malignant neoplasm of lower-inner quadrant of right female breast
C50.312Malignant neoplasm of lower-inner quadrant of left female breast
C50.411Malignant neoplasm of upper-outer quadrant of right female breast
C50.412Malignant neoplasm of upper-outer quadrant of left female breast
C50.511Malignant neoplasm of lower-outer quadrant of right female breast
C50.512Malignant neoplasm of lower-outer quadrant of left female breast
C50.611Malignant neoplasm of axillary tail of right female breast
C50.612Malignant neoplasm of axillary tail of left female breast
C50.811Malignant neoplasm of overlapping sites of right female breast
C50.812Malignant neoplasm of overlapping sites of left female breast
Z85.3Personal history of malignant neoplasm of breast