Breast Implant, Removal and/or Insertion

This policy covers surgical insertion, removal, or replacement of silicone or saline breast implants for medically necessary reconstructive indications — including post‑mastectomy breast reconstruction (and contralateral symmetry procedures), reconstruction after trauma/accident, repair following cancer‑related initial implant surgery, and treatment of local complications (e.g., rupture, extrusion, capsular contracture). Cosmetic breast augmentation and cosmetic removal/replacement unrelated to cancer, increased cancer risk, or trauma are excluded; coverage is governed by the member’s benefit plan, applicable state rules and product‑line limits (e.g., specified fully insured and Medicaid products, not ASO unless elected) and may require documentation.

"Medically necessary reconstructive services intended to restore physical appearance of body structures damaged by trauma."