Medicare Part B Policy WPS Medicare Effective Date 04/01/1996 Revision Date 09/16/2004 Publish Date March 1996 States Affected IL MI WI MN Policy Number GSURG-032 "Indications for specific surgical procedures: BREAST reconstruction of the affected and the contralateral unaffected BREAST following a medically necessary mastectomy is covered (19316, 19318, 19324, 19325, 19340, 19342, 19350,19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396) The applicable ICD-9 codes include: V10.3, 173.5, 174.0-174.9, 175.0-175.9, 198.2, 198.81, 217, 232.5, 233.0, 610.0-610.9 "
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