Medicare Benefits Schedule - Note TN.8.294

Services under augmentation mammaplasty items 45524 and 45528 involve the insertion of a breast prosthesis/prostheses.

Autologous fat grafting in the context of breast cancer or developmental disorders can be claimed under items 45534 and 45535.

Related Items: 45524 45528 45534 45535

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Multiple Operation Rule

Mammaplasty, augmentation (unilateral) in the context of:

(a) breast cancer; or

(b) developmental abnormality of the breast, if there is a difference in breast volume, as demonstrated by an appropriate volumetric measurement technique, of at least:

(i) 20% in normally shaped breasts; or

(ii) 10% in tubular breasts or in breasts with abnormally high inframammary folds.

Applicable only once per occasion on which the service is provided, other than a service associated with a service to which item 45006 or 45012 applies (H)

(Anaes.) (Assist.)

Fee: $844.90 Benefit: 75% = $633.70

(See para TN.8.96, TN.8.294 of explanatory notes to this Category)

Multiple Operation Rule

Mammaplasty, augmentation, bilateral (other than a service to which item 45527 applies), if:

(a) reconstructive surgery is indicated because of:

(i) developmental malformation of breast tissue (excluding hypomastia); or

(ii) disease of or trauma to the breast (other than trauma resulting from previous elective cosmetic surgery); or

(iii) amastia secondary to a congenital endocrine disorder; and

(b) photographic or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes

other than a service associated with a service to which item 45006 or 45012 applies (H)

(Anaes.) (Assist.)

Fee: $1,267.20 Benefit: 75% = $950.40

(See para TN.8.294 of explanatory notes to this Category)

Multiple Operation Rule

Autologous fat grafting, unilateral service (harvesting, preparation and injection of adipocytes) if:

(a) the autologous fat grafting is for one or more of the following purposes:

(i) the correction of defects arising from treatment and prevention of breast cancer in patients with contour defects, greater than or equal to 20% volume asymmetry, post‑treatment pain or poor prosthetic coverage;

(ii) the preparation of post mastectomy thin or irradiated skin flaps in patients intending to have breast reconstruction;

(iii) breast reconstruction in breast cancer patients;

(iv) the correction of developmental disorders of the breast; and

(b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes

Up to a total of 4 services per side (for total treatment of a single breast), other than a service associated with a service to which item 45006 or 45012 applies

(H)

(Anaes.)

Fee: $719.70 Benefit: 75% = $539.80

(See para TN.8.294 of explanatory notes to this Category)

Multiple Operation Rule

Autologous fat grafting, bilateral service (harvesting, preparation and injection of adipocytes) if:

(a) the autologous fat grafting is for one or more of the following purposes:

(i) the correction of defects arising from treatment and prevention of breast cancer in patients with contour defects, greater than or equal to 20% volume asymmetry, post‑treatment pain or poor prosthetic coverage;

(ii) the preparation of post mastectomy thin or irradiated skin flaps in patients intending to have breast reconstruction;

(iii) breast reconstruction in breast cancer patients;

(iv) the correction of developmental disorders of the breast; and

(b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes

Up to a total of 4 services, other than a service associated with a service to which item 45006 or 45012 applies

 (H)

(Anaes.)

Fee: $1,259.55 Benefit: 75% = $944.70

(See para TN.8.294 of explanatory notes to this Category)