BREAST IMPLANT, REMOVAL OR REPLACEMENT

Status
Active
Medical and Behavioral Health Policy
Section: Surgery
Policy Number: IV-14
Effective Date: 03/23/2015
Blue Cross and Blue Shield of Minnesota medical policies do not imply that members should not receive specific services
based on the recommendation of their provider. These policies govern coverage and not clinical practice. Providers are
responsible for medical advice and treatment of patients. Members with specific health care needs should consult an
appropriate health care professional.
BREAST IMPLANT, REMOVAL OR REPLACEMENT
Description:
Breast implants are generally considered cosmetic except as part of
reconstructive surgery for treatment of breast cancer or prophylactic
mastectomy. The Federal Women’s Health and Cancer Rights Act of
1998 (PL 105-277) and Minnesota law require coverage of all stages
of reconstruction of the breast on which a mastectomy was
performed, as well as surgery and reconstruction of the other breast
to produce a symmetrical appearance.
Capsular contracture is the most common complication associated
with breast implants, and severity is graded according to the Baker
classification (see Definitions). Other complications such as
hematoma, seroma, or infection are initially addressed through
medical intervention. In those instances where complications are
not responsive to repeated medical treatment, removal of the
implant may be required to resolve the condition.
In 1991, the U.S. Food and Drug Administration (FDA) began
evaluating health concerns related to the rupture and leakage of
silicone breast implants, including development of autoimmune
disease. There is no conclusive evidence to support a causal
relationship between silicone implants and autoimmune disease.
Definitions:
Baker classification of capsular contracture:
Grade I: The breast is soft without palpable thickening.
Grade II: The breast has some firmness. The implant can be
palpated but is not visible.
Grade III: The breast is firm. The implant can be palpated easily. The
implant or its distortion may be visible.
Grade IV: The breast is hard, painful, and tender with significant
distortion.
Policy:
I.
Initial Insertion/Placement of Breast Implants
A. Initial insertion/placement of breast implants may be
considered MEDICALLY NECESSARY for reconstructive
purposes following:
1. Mastectomy for breast cancer; OR
2. Prophylactic mastectomy.
B. Initial insertion/placement of breast implants is considered
COSMETIC for all other indications, including but not
limited to breast augmentation.
II. Removal of Breast Implants
A. Removal of breast implants may be considered
MEDICALLY NECESSARY when:
1. The original implants were placed for reconstructive
purposes post-mastectomy, as described in section IA;
OR
2. The original implants were placed for cosmetic
purposes, as described in section IB, AND one or more
of the following complications are present:
a. Capsular contracture of Baker Class IV causing
severe pain or hardening of the implant;
b. Confirmed leakage/rupture of a silicone implant
with silicone migration resulting in pain, lumps,
granulomas and increasing fibrosis;
c. Recurrent infection secondary to the implant that
does not resolve with medical treatment including
antibiotics;
d. Recurrent seroma or hematoma that does not
resolve with repeated drainage; or
e. Implant extrusion through the skin; or
f. Implant interference with diagnostic evaluation of
suspected breast cancer or treatment of known
breast cancer.
B. Removal of breast implants originally placed for cosmetic
purposes, as described in section IB, is considered
COSMETIC for all other indications, including but not
limited to:
1. Aesthetic appearance;
2. Malposition of the implant; or
3. Anxiety related to the implant.
III. Replacement of Breast Implants
A. Replacement of breast implants may be considered
MEDICALLY NECESSARY when the original implants
were placed for reconstructive purposes post-mastectomy,
as described in section IA.
B. Replacement of breast implants is considered COSMETIC
when the original implants were placed for cosmetic
purposes, as described in section IB.
Coverage:
Blue Cross and Blue Shield of Minnesota medical policies apply
generally to all Blue Cross and Blue Plus plans and products. Benefit
plans vary in coverage and some plans may not provide coverage for
certain services addressed in the medical policies.
Medicaid products and some self-insured plans may have additional
policies and prior authorization requirements. Receipt of benefits is
subject to all terms and conditions of the member’s summary plan
description (SPD). As applicable, review the provisions relating to a
specific coverage determination, including exclusions and limitations.
Blue Cross reserves the right to revise, update and/or add to its
medical policies at any time without notice.
For Medicare NCD and/or Medicare LCD, please consult CMS or
National Government Services websites.
Refer to the Pre-Certification/Pre-Authorization section of the Medical
Behavioral Health Policy Manual for the full list of services,
procedures, prescription drugs, and medical devices that require Precertification/Pre-Authorization. Note that services with specific
coverage criteria may be reviewed retrospectively to determine if
criteria are being met. Retrospective denial of claims may result if
criteria are not met.
Coding:
The following codes are included below for informational purposes
only, and are subject to change without notice. Inclusion or exclusion
of a code does not constitute or imply member coverage or provider
reimbursement.
CPT:
11970 Replacement of tissue expander with permanent prosthesis
19325 Mammaplasty, augmentation; with prosthetic implant
19328 Removal of intact mammary implant
19330 Removal of mammary implant material
19340 Immediate insertion of breast prosthesis following mastopexy,
mastectomy or in reconstruction
19342 Delayed insertion of breast prosthesis following mastopexy,
mastectomy or in reconstruction
19396 Preparation of moulage for custom breast implant
HCPCS:
C1789 Prosthesis, breast (implantable)
L8600 Implantable breast prosthesis, silicone or equal
Policy
History:
Developed April 20, 1994
Most recent history:
Reviewed October 12, 2011
Revised November 14, 2012
Reviewed November 13, 2013
Revised January 14, 2015
Cross
Reference:
Mastopexy, IV-33
Current Procedural Terminology (CPT®) is copyright 2014 American Medical
Association. All Rights Reserved. No fee schedules, basic units, relative values, or
related listings are included in CPT. The AMA assumes no liability for the data
contained herein. Applicable FARS/DFARS restrictions apply to government use.
Copyright 2015 Blue Cross Blue Shield of Minnesota.