Breast Reconstructive Surgery

Aetna covers breast reconstruction (including autologous fat grafting and contralateral procedures for symmetry) when performed after a medically necessary mastectomy or a lumpectomy that causes significant deformity, for prompt repair after trauma, or to correct functional chest‑wall deformity in Poland syndrome when CPB‑0272 criteria are met. The policy excludes specified experimental/investigational products and techniques (e.g., Artia, Biodesign nipple cylinder, SimpliDerm, nerve coaptation, body‑lift perforator flap, 3‑D volumetric imaging) and lists CPT codes 0694T and 64910–64913 (and related HCPCS/ICD‑10 indications) as not covered.

"Pathology and oncologic records as applicable (e."

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