CommercialCoverageMedium impact
Breast Reconstruction Surgery and Prophylactic Breast Cancer Risk-Reducing Mastectomy 10.01.01
Excellus BlueCross BlueShield·NY · Plastic Surgery, General Surgery, OB-GYN +1 more·Cosmetic / Reconstructive Surgery
Effective date
Aug 21, 2025
We identified it
Jun 20, 2026
Summary
Excellus BlueCross BlueShield updated their breast reconstruction surgery and prophylactic mastectomy policy, effective August 21, 2025. The policy expands coverage for reconstructive breast surgery after mastectomy and clarifies coverage for risk-reducing mastectomies for high-risk individuals with specific genetic variants or risk factors.
Action Required
Before August 21, 2025: Review current breast reconstruction and prophylactic mastectomy billing practices to ensure compliance with updated coverage criteria. Verify that documentation includes appropriate high-risk factors (BRCA1/2 variants, lobular carcinoma in situ, chest radiation history, or other specified genetic variants) for prophylactic mastectomy claims. Update billing staff on expanded coverage for nipple-sparing and skin-sparing mastectomy techniques as medically appropriate alternatives.