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Texas · Federal IDR + state pathway
Out of network Revision of reconstructed breast in Texas, CPT 19380
Texas runs its own process alongside the federal one. Which applies depends on the plan.
An underpaid Revision of reconstructed breast (CPT 19380) claim in Texas does not have one dispute route — it has two, and picking the wrong one costs the claim. State-regulated plans — including the Texas ERS and TRS government plans — follow Texas's process. Self-funded ERISA plans follow the federal IDR process. Confirm routing by plan type before filing.
- Code
- CPT 19380
- Typical setting
- hospital or ASC
- Texas pathway
- Federal IDR + state pathway
Revision of a previously reconstructed breast.
How Texas handles an out-of-network Revision of reconstructed breast payment
Texas resolves out-of-network disputes through TDI-administered mediation for facilities and binding arbitration for out-of-network physicians (SB 1264, 2019; Texas Insurance Code ch. 1467). The arbiter sets a 'reasonable amount' weighing the 80th percentile of billed charges and the 50th percentile of in-network rates, and balance billing is banned.
Either party may initiate; physicians request arbitration within 90 days of payment and facilities have 180 days for mediation.
The arbiter determines a 'reasonable amount' by statutory factors, and similar claims may be batched.
Routing decides the deadline. State-regulated plans — including the Texas ERS and TRS government plans — follow Texas's process. Self-funded ERISA plans follow the federal IDR process. Confirm routing by plan type before filing. Two patients can receive the same Revision of reconstructed breast at the same facility and their claims follow different processes with different clocks. Confirm plan type against the CMS applicability chart before filing.
Why CPT 19380 gets paid short out of network
Anchored to the qualifying payment amount (QPA)
The plan pays Revision of reconstructed breast at its own qualifying payment amount — its median in-network rate for the area — and treats that as the answer. Under the No Surprises Act the QPA is the plan's opening anchor, not a cap, and certified IDR entities weigh several other factors against it.
Out-of-network reduction with no contract on file
With no negotiated rate for Revision of reconstructed breast (CPT 19380), the allowed amount is reduced to an out-of-network schedule that rarely reflects what the breast procedure actually involves in a hospital or ASC setting.
This is the national picture for the code. For the full breakdown see Revision of reconstructed breast (CPT 19380), and for every procedure disputed in this state see Texas out-of-network IDR.
CPT 19380 in Texas — common questions
Does a Revision of reconstructed breast claim in Texas go to state or federal IDR?
State-regulated plans — including the Texas ERS and TRS government plans — follow Texas's process. Self-funded ERISA plans follow the federal IDR process. Confirm routing by plan type before filing. For CPT 19380, the deciding factor is the patient's plan type rather than the procedure — the same code can route either way for two different patients at the same facility.
What is the deadline to dispute an out-of-network Revision of reconstructed breast payment in Texas?
Either party may initiate; physicians request arbitration within 90 days of payment and facilities have 180 days for mediation. Missing the window forfeits the claim regardless of its merits, which is the most common way a Revision of reconstructed breast dispute is lost in Texas.
Is CPT 19380 worth disputing in Texas?
Providers prevail in roughly 88% of federal IDR determinations they contest, and Revision of reconstructed breast is hospital or asc work that is routinely paid below billed charge out of network. The question is usually whether the claim is eligible and the deadline is still open — which is what we check first, at no cost.
CPT 19380 in other states
Routing and deadlines change at the state line, even for the same procedure and payer.
More plastic and reconstructive surgery codes: Plastic and reconstructive surgery out-of-network disputes
Find out whether this Texas claim is still eligible
Send one denied EOB. We will tell you which process it routes to, whether the window is still open, and what the claim is worth — before you commit to anything.
Medically & clinically reviewed by Dr. John M. Abrahams, MD
Board-certified neurosurgeon and founder of Sydra · Last reviewed September 2026 · About the author
Sources
Figures reflect the published federal record across all disputes, not a prediction about any individual claim. This is general information, not legal or financial advice.
No outcome is guaranteed. Results vary by claim, payer, specialty, and documentation. Which process applies depends on plan type; confirm routing against the CMS applicability chart before filing. This is general information, not legal or financial advice.