SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

This policy addresses breast procedures, including reconstructive breast surgery and breast implants, with specific criteria for implant removal. Implant removal is covered when medically necessary for documented rupture of silicone gel implants (confirmed by mammography, ultrasound, or MRI), and for silicone gel, saline, or “alternative” implants when there is infection, implant exposure/extrusion, or pain due to Baker Class IV capsular contracture. Removal is not covered for ruptured saline or “alternative” implants, nor for any implant when requested due to systemic/autoimmune symptoms, personal anxiety, or pain not related to contracture or rupture; reconstructive surgery is distinguished from cosmetic procedures and pertains to restoring the breast after medically necessary surgery or trauma.

"Removal of implantspartially or completely filledwithSilicone Gelis consideredmedically necessarywhen there is documented implant rupture (that is, using mammography, ultrasound, or MRI)."