Aetna considers the removal of breast implants medically necessary for members who meet the following selection criteria.
For members who have undergone either cosmetic augmentation mammoplasty or breast reconstruction following a medically necessary mastectomy (e.g., mastectomy for breast cancer or a prophylactic mastectomy (see CPB 0227 - BRCA Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy)), removal of a breast implant and capsulectomy or capsulotomy is considered medically necessary for any of the following indications:
For members whose breast reconstruction followed a medically necessary mastectomy (i.e., mastectomy for breast cancer or a prophylactic mastectomy), removal of a breast implant and capsulectomy or capsulotomy is also considered medically necessary for these additional indications:
Removal of ruptured saline-filled breast implants is not considered medically necessary for members who have previously undergone cosmetic breast augmentation mammoplasty.
If any of the above criteria for removal of a breast implant is met unilaterally, Aetna also considers medically necessary removal of the implant and capsulectomy or capsulotomy in the other breast if both implants are removed at the same time.
Requests for the removal of breast implants for any of the following indications is subject to medical review:
Silicone Implant Removal for Autoimmune Disease:
Aetna does not consider either of the following medically necessary:
Reinsertion of Breast Implants:
Although Aetna considers the removal of breast implants medically necessary for medical indications even if the implants were originally inserted for cosmetic purposes, Aetna considers the re-insertion of new breast implants cosmetic in this situation. Aetna considers medically necessary the insertion of initial breast implants and the replacement of breast implants inserted following a medically necessary mastectomy (i.e., mastectomy for breast cancer or a prophylactic mastectomy) or for women with Poland's syndrome meeting the criteria in CPB 0272 - Pectus Excavatum and Poland's Syndrome: Surgical Correction.
|Class I||Augmented breast feels soft as a normal breast.|
|Class II||Augmented breast is less soft and implant can be palpated, but is not visible.|
|Class III||Augmented breast is firm, implant is palpable and the implant (or distortion) is visible.|
|Class IV||Augmented breast is hard, painful, cold, tender, and distorted.|
See also CPB 0185 - Breast Reconstructive Surgery.Background
At the time of the Food and Drug Administration (FDA) hearing on silicone breast implants in February of 1992, the FDA advised that ruptured silicone implants should be removed since the health risks of extruded silicone are not known. At the same time, the FDA panel acknowledged that asymptomatic rupture may be present in up to 4 % of women with silicone implants, but the FDA specifically did not recommend screening for asymptomatic ruptures.
Rupture of silicone implants can be subdivided into 2 categories: (i) intra-capsular and (ii) extra-capsular. After implantation, a reactive fibrous capsule is formed around the implant. If the extruded silicone is contained by this fibrous capsule the rupture is termed intra-capsular. If the silicone gel is extruded beyond the capsule, the rupture is termed extra-capsular. Extra-capsular silicone can induce granulomatous reaction and can occasionally migrate to the axillary lymph nodes, producing a lymphadenopathy, which can mimic cancer. Clinically, extra-capsular ruptures are often associated with a change in size and consistency of the breast. Extra-capsular ruptures can usually be identified on mammography or other imaging studies. Explantation of these implants is clearly indicated.
The health consequences of intra-capsular ruptures are uncertain since theoretically the silicone is contained within the fibrous capsule. Furthermore it is known that intact implants routinely “bleed” microscopic silicone particles, which are also contained within the fibrous capsule. Nevertheless, an intra-capsular rupture can evolve to an extra-capsular rupture and the FDA has indicated that ruptured implants, whether intra-capsular or extra-capsular, should be explanted as well.
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|CPT codes covered if selection criteria are met:|
|19328||Removal of intact mammary implant|
|19330||Removal of mammary implant material|
|19370||Open periprosthetic capsulotomy, breast|
|19371||Periprosthetic capsulectomy, breast|
|Other CPT codes related to the CPB:|
|19120 - 19126||Breast, excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, one or more lesions|
|19316 - 19380||Breast, repair and/or reconstruction procedures|
|Other HCPCS codes related to the CPB:|
|L8020 - L8039||Breast prostheses|
|L8600||Implantable breast prosthesis, silicone or equal|
|ICD-10 codes covered if selection criteria are met:|
|C50.011 - C50.929||Malignant neoplasm of breast|
|T85.41x+ - T85.49x+||Mechanical complication of breast prosthesis and implant|
|T85.79x+||Infection and inflammatory reaction due to other internal prosthetic devices, implants, or grafts|