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. PA is also waived for certain skin grafting codes when performed in conjunction with breast reconstruction when one of the following ICD diagnosis codes for breast cancer or a personal history of breast cancer is present. (Skin grafting is identified by CPT codes 15771-15774.)
| ICD Diagnosis Code | Description |
|---|---|
| C50.011 | Malignant neoplasm of nipple and areola, right female breast |
| C50.012 | Malignant neoplasm of nipple and areola, left female breast |
| C50.111 | Malignant neoplasm of central portion of right female breast |
| C50.112 | Malignant neoplasm of central portion of left female breast |
| C50.211 | Malignant neoplasm of upper-inner quadrant of right female breast |
| C50.212 | Malignant neoplasm of upper-inner quadrant of left female breast |
| C50.311 | Malignant neoplasm of lower-inner quadrant of right female breast |
| C50.312 | Malignant neoplasm of lower-inner quadrant of left female breast |
| C50.411 | Malignant neoplasm of upper-outer quadrant of right female breast |
| C50.412 | Malignant neoplasm of upper-outer quadrant of left female breast |
| C50.511 | Malignant neoplasm of lower-outer quadrant of right female breast |
| C50.512 | Malignant neoplasm of lower-outer quadrant of left female breast |
| C50.611 | Malignant neoplasm of axillary tail of right female breast |
| C50.612 | Malignant neoplasm of axillary tail of left female breast |
| C50.811 | Malignant neoplasm of overlapping sites of right female breast |
| C50.812 | Malignant neoplasm of overlapping sites of left female breast |
| Z85.3 | Personal history of malignant neoplasm of breast |