Commercial

Medical Policy

Notification

Removal of Breast Implants

Notification Issue Date:

This version of the policy will become effective 06/08/2020. This policy has been updated in consideration of recommendations of the US Food and Drug Administration (FDA) and 2019 National Comprehensive Cancer Network (NCCN) Consensus Guidelines on the Diagnosis and Treatment of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). In addition, criteria were added to address the removal of a breast implant in the contralateral breast.

The following indication was added to this policy for the removal silicone gel-filled and saline-filled breast implant(s):

Individuals diagnosed with breast implant--associated anaplastic large cell lymphoma (BIA-ALCL)

The following criteria were added to the policy for the removal of silicone gel-filled breast implants to address the contralateral (unaffected) breast:

When the above criteria for removal of a silicone gel-filled breast implant are met unilaterally AND the implant was originally placed for a medically necessary indication (e.g., chest wall deformities such as Pectus Excavatum or Poland’s Syndrome, repair of breast asymmetry due to a medically necessary mastectomy or lumpectomy, repair of breast asymmetry due to trauma), then removal of the implant in the contralateral breast is considered medically necessary to achieve breast symmetry, and is therefore covered when both implants are removed at the same time.

When the above criteria for removal of a saline-filled breast implant are met unilaterally AND the implant was originally placed for a medically necessary indication (e.g., chest wall deformities such as Pectus Excavatum or Poland’s Syndrome, repair of breast asymmetry due to a medically necessary mastectomy or lumpectomy, repair of breast asymmetry due to trauma), then removal of the implant in the contralateral breast is considered medically necessary to achieve breast symmetry, and is therefore covered when both implants are removed at the same time.

In addition, when a individual has been diagnosed with unilateral breast implant-associated anaplastic large cell lymphoma (BIALCL), removal of both implants (affected and the contralateral breast) is considered medically necessary and is therefore covered regardless why the implants were originally placed.

The following ICD- 10CM codes have been added to this policy:

C84.60 Anaplastic large cell lymphoma, ALK-positive, unspecified site
C84.61 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of head, face, and neck
C84.62 Anaplastic large cell lymphoma, ALK-positive, intrathoracic lymph nodes
C84.63 Anaplastic large cell lymphoma, ALK-positive, intra-abdominal lymph nodes
C84.64 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of axilla and upper limb
C84.65 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of inguinal region and lower limb
C84.66 Anaplastic large cell lymphoma, ALK-positive, intrapelvic lymph nodes
C84.67 Anaplastic large cell lymphoma, ALK-positive, spleen
C84.68 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of multiple sites
C84.69 Anaplastic large cell lymphoma, ALK-positive, extranodal and solid organ sites
C84.70 Anaplastic large cell lymphoma, ALK-negative, unspecified site
C84.71 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of head, face, and neck
C84.72 Anaplastic large cell lymphoma, ALK-negative, intrathoracic lymph nodes
C84.73 Anaplastic large cell lymphoma, ALK-negative, intra-abdominal lymph nodes
C84.74 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of axilla and upper limb
C84.75 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of inguinal region and lower limb
C84.76 Anaplastic large cell lymphoma, ALK-negative, intrapelvic lymph nodes
C84.77 Anaplastic large cell lymphoma, ALK-negative, spleen
C84.78 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of multiple sites
C84.79 Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites
Z48.3 Aftercare following surgery for neoplasm

Title:

Removal of Breast Implants

Policy #:

11.08.14p

Policy

MEDICALLY NECESSARY

The removal of breast implant(s) is considered medically necessary and, therefore, covered for the following indications:

Documented implant rupture when the following criteria are met:

Saline-filled implant - removal of the ruptured implant is considered medically necessary and is therefore covered if the implant was originally placed for a medically necessary indication (e.g., chest wall deformities such as Pectus Excavatum or Poland’s Syndrome, repair of breast asymmetry due to a medically necessary mastectomy or lumpectomy, repair of breast asymmetry due to trauma)
Silicone-gel filled implant - removal of the ruptured implant is considered medically necessary and is therefore covered regardless of why the implant was originally placed

Extrusion
Infection or rejection
Siliconoma or granuloma
Baker Class III contracture (breast is firm, palpable, and the implant [or its distortion] is visible) only when the implant(s) was placed as part of a medically necessary reconstructive procedure
Baker Class IV contracture (breast is hard, painful, cold, tender, and distorted)
Interference with diagnosis of breast cancer
Surgical treatment of breast cancer
Individuals diagnosed with breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)

When the above criteria for removal of a breast implant is met unilaterally AND the implant was originally placed for a medically necessary indication (e.g., chest wall deformities such as Pectus Excavatum or Poland’s Syndrome, repair of breast asymmetry due to a medically necessary mastectomy or lumpectomy, repair of breast asymmetry due to trauma), then removal of the implant in the contralateral breast is considered medically necessary to achieve breast symmetry, and is therefore covered when both implants are removed at the same time.

In addition, when a individual has been diagnosed with unilateral breast implant--associated anaplastic large cell lymphoma (BIALCL), removal of both implants (affected and the contralateral breast) is considered medically necessary and is therefore covered regardless of why the implants were originally placed.

BENEFIT CONTRACT EXCLUSION
The removal of breast implant(s) for any other indication is considered cosmetic and therefore a benefit contract contract exclusion for most products of the Company.

Services that are cosmetic are a benefit contract exclusion for most products of the Company. Therefore, they are not eligible for reimbursement consideration.

Subsequent surgery to improve, correct, or further alter the appearance of a body part that has previously undergone a cosmetic surgical procedure is considered a revision of a previously performed cosmetic procedure. Under most circumstances, cosmetic services are considered benefit contract exclusions. Individual benefits must be verified.

WOMEN'S HEALTH AND CANCER RIGHTS ACT (WHCRA)

The Women's Health and Cancer Rights Act was enacted as a federal mandate in October 1998. The federal mandate addresses reconstructive breast surgery following a mastectomy, and requires coverage for:

(1) All stages of reconstruction of the breast on which the mastectomy has been performed;
(2) Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
(3) Prostheses and physical complications of mastectomy, including lymphedemas.

REQUIRED DOCUMENTATION

To support the medical necessity of the removal of a breast implant, the medical record documentation must include:

Documentation of the original indication for implantation
Reason for the implant removal and the results of any mammogram, ultrasound, and/or magnetic resonance imaging (MRI) as appropriate

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, the removal of breast implant(s) is covered under the medical benefits of the Company's products when the medical necessity criteria listed in this medical policy are met.

Description

Implanted breast prostheses are silicone shells filled with saline and/or silicone gel. The implantation can be either for medically necessary indications (e.g., reconstruction following mastectomy, surgery/trauma) or for cosmetic reasons. Reconstructive treatment is defined as any medical or surgical service designed to restore bodily function or to correct a deformity that has resulted from trauma or the treatment of disease. Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone do not constitute improvement in physiologic function.

Complications can occur with breast implants that may require removal of the implant. Examples of complications include infection, extrusion (implant exposure at the surface of the skin), rupture, and contracture. Research evidence reveals that the incidence of microbial contamination of the luminal saline of the implant is unlikely. Normal saline is a physiologic solution consistent with an organism's normal functioning.

A contracture occurs when the capsule surrounding a breast implant tightens. Extreme cases can cause the breast to feel hard and painful. Disfigurement may also result if the capsule surrounding one implant contracts and the other does not, or if the capsule contracts unevenly. Contractures have been graded according to the Baker Classification as follows:

Baker Grade I: Augmented breast feels as soft as a normal breast.
Baker Grade II: Breast is less soft, and the implant can be palpated but is not visible.
Baker Grade III: Breast is firm, palpable, and the implant (or its distortion) is visible.
Baker Grade IV: Breast is hard, painful, cold, tender, and distorted.
(US Food and Drug Administration [FDA], 2004)

Breast implant--associated anaplastic large cell lymphoma (BIA-ALCL) is another complication that that can occur with breast implants. BIA-ALCL has been reported most commonly in individuals with a history of a textured breast implant. BIA-ALCL is not a cancer of the breast tissue itself, but of the scar envelope that the body naturally forms around a breast implant, called the capsule. Symptoms of BIA-ALCL include a swelling of the breast that develops over several years after insertion of textured breast implants, or a lump in the breast or lymph node in the armpit. Less common symptoms include overlying skin rash, fever, and weight loss. Treatment of BIA-ALCL follows standardized guidelines established by the National Comprehensive Cancer Network (NCCN). The US Food and Drug Administration [FDA] does not recommend removal of implants for individuals that are not having symptoms. For confirmed BIA-ALCL, current NCCN recommendations call for total capsulectomy, removal of the implant, as well as excision of any masses.

COSMETIC SERVICES

Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone do not constitute improvement in physiologic function.

References

American Association of Plastic Surgeons (AAPS). AAPS Consensus on Breast Implant-Associated Anaplastic Large-Cell Lymphoma. Plast Reconstr Surg. 2024;154(3):473-483.

American Society of Plastic Surgeons (ASPS). BIA-ALCL Resources. [ASPS Web site]. 11/01/2024. Available at: https://www.plasticsurgery.org/for-medical-professionals/health-policy/bia-alcl-physician-resources. Accessed March 11, 2026.

American Society of Plastic Surgeons (ASPS). Breast Implant Safety: What Patients Need to Know. [ASPS Web site]. 03/08/2023. Available at: https://www.plasticsurgery.org/patient-safety/breast-implant-safety. Accessed March 11, 2026.

American Society of Plastic Surgeons (ASPS). Practice Parameter. Treatment principles of silicone breast implants. [ASPS Web site]. 03/01/2005. Available at: http://www.plasticsurgery.org/for-medical-professionals/advocacy/key-issues/breast-procedures.html. [The link to this reference is no longer active to the public on the ASPS Web site]. Accessed March 11, 2026.

Brown MH, Markus YM, Belchetz B, et al. Microbial growth in saline breast implants and saline tissue expanders (Abstract). Plastic Reconstr Surg. 2002;109(7):2242-2244.

Chung KC, Wilkins EG, Beil RJ JR, et al. Diagnosis of silicone gel breast implant rupture by ultrasonography. Plast Reconstr Surg. 1996;97(1):104-109.

Clemens MW, Jacobsen ED, Horwitz SM. 2019 NCCN Consensus Guidelines on the Diagnosis and Treatment of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). Aesthetic Surgery Journal. 2019;39(S1):S3-S13.

Ferguson JH. Silicone breast implants and neurologic disorders. Report of the Practice Committee of the American Academy of Neurology. Neurology. 1997;48(6):1504-1507.

Gabriel SE, O'Fallon WM, Kurland LT, et al. Risk of connective-tissue diseases and other disorders after breast implantation. N Engl J Med. 1994;330(24):1697-1702.

Gherardini G, Zaccheddu R, Basoccu G. Trilucent breast implants: voluntary removal following the Medical Device Agency recommendation. Report on 115 consecutive patients. Plast Reconstr Surg. 2004;113(3):1024-1027.

Hennekens CH, Lee IM, Cook NR, et al. Self-reported breast implants and connective-tissue disease in female health professionals. A retrospective cohort study. JAMA. 1996;275(8):616-621.

Marotta JS, Goldberg EP, Habal MB, et al. Silicone gel breast implant failure: evaluation of properties of shells and gels for explanted prostheses and meta-analysis of literature rupture data. Ann Plast Surg. 2002;49(3):227-247.

Mentor Corporation. Saline-Filled Breast Implant Surgery: Making an Informed Decision. [US Food and Drug Administration (FDA) Web site]. 2009. Available at: http://www.fda.gov/downloads/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm064453.pdf. Accessed March 11, 2026.

National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. T-Cell Lymphomas. v2.2026. [NCCN Web site]. Available at: https://www.nccn.org/professionals/physician_gls/pdf/t-cell.pdf. Accessed March 11, 2026.

National Research Center (NRC) for Women & Families. Breast Implants: A Research and Regulatory Summary. [NRC Web site]. Available at: http://www.center4research.org/breast-implants-research-regulatory-summary/. Accessed March 11, 2026.

Netscher DT, Weizer G, Malone RS, et al. Diagnostic value of clinical examination and various imaging techniques for breast implant rupture as determined in 81 patients having implant removal. South Med J. 1996;89(4):397-404.

Novitas Solutions, Inc. Local Coverage Article (LCA). A56587: Cosmetic and Reconstructive Surgery. [Novitas Solutions Web site]. Original: 05/30/2019. (Revised: 11/17/2025). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=56587. Accessed March 11, 2026.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L35090: Cosmetic and Reconstructive Surgery. [Novitas Solutions Web site]. Original: 10/01/2015. (Revised: 07/11/2021). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=35090&ver=95. Accessed March 11, 2026.

Peters W, Smith D, Fornasier V, et al. An outcome analysis of 100 women after explantation of silicone gel breast implants. Ann Plast Surg. 1997;39(1):9-19.

Samuels JB, Rohrich RJ, Weatherall PT, et al. Radiographic diagnosis of breast implant rupture: current status and comparison of techniques. Plast Reconstr Surg. 1995;96(4):865-877.

Sanchez-Guerrero J, Colditz GA, Karlson EW, et al. Silicone breast implants and the risk of connective-tissue diseases and symptoms. N Engl J Med. 1995;332(25):1666-1670.

Siggelkow W, Klosterhalfen B, Klinge U, et al. Analysis of local complications following explantation of silicone breast implants. Breast. 2004;13(2):122-128.

Silverman BG, Brown SL, Bright RA, et al. Reported complications of silicone gel breast implants: an epidemiologic review. Ann Intern Med. 1996;124(8):744-756.

Song JW, Kim HM, Bellfi LT, et al. The effect of study design biases on the diagnostic accuracy of magnetic resonance imaging for detecting silicone breast implant ruptures: a meta-analysis. Plast Reconstr Surg. 2011;127(3):1029-1044.

Spear SL, Howard MA, Boehmler JH, et al. The infected or exposed breast implant: management and treatment strategies. Plast Reconstr Surg. 2004;113(6):1634-1644.

Thomas WO III, Harper LL, Wong SW, et al. Explantation of silicone breast implants. Am Surg. 1997;63(5):421-429.

US Department of Labor; Employee Benefits Security Administration. Fact Sheet: Women’s Health and Cancer Rights Act. [US Department of Labor Web site]. Available at: https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/fact-sheets/whcra.pdf. Accessed March 11, 2026.

US Department of Labor; Employee Benefits Security Administration. Your Rights After a Mastectomy. [US Department of Labor Web site]. September 2018. Available at: https://www.dol.gov/sites/dolgov/files/ebsa/about-ebsa/our-activities/resource-center/publications/your-rights-after-a-mastectomy.pdf. Accessed March 11, 2026.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Breast Implants home page. [FDA Web site]. 09/17/13 (Page updated 03/08/2023). Available at: http://www.fda.gov/medicaldevices/productsandmedicalprocedures/implantsandprosthetics/breastimplants/default.htm. Accessed March 11, 2026.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Breast Implants: Local Complications and Adverse Outcomes. [FDA Web site]. Available at: https://wayback.archive-it.org/7993/20170112132504/http://www.fda.gov/downloads/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/UCM259894.pdf. Accessed March 11, 2026.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Questions and Answers about Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). [FDA Web site]. 10/23/2019. Available at: https://www.fda.gov/medical-devices/breast-implants/questions-and-answers-about-breast-implant-associated-anaplastic-large-cell-lymphoma-bia-alcl. Accessed March 11, 2026.

Coding

CPT Procedure Code Number(s)

19328, 19330, 19371

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

See Attachment A.

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 11.08.14p:

04/29/2026	This policy has been reissued in accordance with the Company's annual review process.
10/01/2025	Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time. This policy has been identified for an ICD-10 code update, effective 10/01/2025. The following ICD-10 codes have been added to this policy: C50.A0 Malignant inflammatory neoplasm of unspecified breast C50.A1 Malignant inflammatory neoplasm of right breast C50.A2 Malignant inflammatory neoplasm of left breast

04/29/2026

This policy has been reissued in accordance with the Company's annual review process.

10/01/2025

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

This policy has been identified for an ICD-10 code update, effective 10/01/2025.

The following ICD-10 codes have been added to this policy:

C50.A0 Malignant inflammatory neoplasm of unspecified breast

C50.A1 Malignant inflammatory neoplasm of right breast

C50.A2 Malignant inflammatory neoplasm of left breast

Revisions From 11.08.14o:

07/09/2025	This policy has been reissued in accordance with the Company's annual review process.
10/01/2024	This policy has been identified for a code update, effective 10/01/2024. The following ICD-10 codes have been added to Attachment A of this policy: T81.328A Disruption or dehiscence of closure of other specified internal operation (surgical) wound, initial encounter T81.328D Disruption or dehiscence of closure of other specified internal operation (surgical) wound, subsequent encounter T81.328S Disruption or dehiscence of closure of other specified internal operation (surgical) wound, sequela T81.329A Deep disruption or dehiscence of operation wound, unspecified, initial encounter T81.329D Deep disruption or dehiscence of operation wound, unspecified, subsequent encounter T81.329S Deep disruption or dehiscence of operation wound, unspecified, sequela The following ICD-10 codes have been deleted from Attachment A of this policy: T81.32XA, T81.32XD, T81.32XS

07/09/2025

This policy has been reissued in accordance with the Company's annual review process.

10/01/2024

This policy has been identified for a code update, effective 10/01/2024.

The following ICD-10 codes have been added to Attachment A of this policy:

T81.328A Disruption or dehiscence of closure of other specified internal operation (surgical) wound, initial encounter
T81.328D Disruption or dehiscence of closure of other specified internal operation (surgical) wound, subsequent encounter
T81.328S Disruption or dehiscence of closure of other specified internal operation (surgical) wound, sequela
T81.329A Deep disruption or dehiscence of operation wound, unspecified, initial encounter
T81.329D Deep disruption or dehiscence of operation wound, unspecified, subsequent encounter
T81.329S Deep disruption or dehiscence of operation wound, unspecified, sequela

The following ICD-10 codes have been deleted from Attachment A of this policy:

T81.32XA, T81.32XD, T81.32XS

Revisions From 11.08.14n:

05/29/2024

This policy has been reissued in accordance with the Company’s annual review process.

06/05/2023

This version of the policy will become effective 06/05/2023.

The policy was updated to communicate that the removal of a saline-filled breast implant for a documented implant rupture is considered Medically Necessary when the implant was originally placed for a medically necessary indication.

The policy sections addressing the removal of silicone gel-filled implants and saline-filled implants were combined into one policy statement addressing the removal of breast implants in general.

The following CPT Procedure code has been removed from this policy: 19370

The following ICD-10 Diagnosis codes have been added to this policy: N61.20, N61.21, N61.22, N61.23, Z98.82

The following ICD-10 Diagnosis codes have been removed from this policy: T81.30XS, T81.31XS, T81.32XS, T81.40XS, T81.41XS, T81.42XS, T81.43XS, T81.44XS, T81.49XS, T85.41XS, T85.42XS, T85.43XS, T85.44XS, T85.49XS, T85.79XS, T85.818S, T85.828S, T85.838S, T85.848S, Z44.30, Z44.31, Z44.32, Z90.10, Z90.11, Z90.12, Z90.13

Revisions From 11.08.14m:

05/18/2022	This policy has been reissued in accordance with the Company’s annual review process.
10/01/2021	This policy has been identified for the ICD-10 code update, effective 10/01/2021. Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time. The following ICD-10 code has been added to Attachment A of this policy: C84.7A Anaplastic large cell lymphoma, ALK-negative, breast

Revisions From 11.08.14l:

08/25/2021	The policy has been reviewed and reissued to communicate the Company’s continuing position on Removal of breast implants.
01/01/2021	This policy has been identified for the CPT code update, effective 01/01/2021. Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time. The following CPT code narratives have been revised in this policy: 19328, 19330, 19370, 19371

Revisions From 11.08.14k:

06/08/2020

Individuals diagnosed with breast implant--associated anaplastic large cell lymphoma (BIA-ALCL)

The following criteria were added to the policy for the removal of silicone gel-filled breast implants to address the contralateral (unaffected) breast:

When the above criteria for removal of a silicone gel-filled breast implant are met unilaterally AND the implant was originally placed for a medically necessary indication (e.g., chest wall deformities such as Pectus Excavatum or Poland’s Syndrome, repair of breast asymmetry due to a medically necessary mastectomy or lumpectomy, repair of breast asymmetry due to trauma), then removal of the implant in the contralateral breast is considered medically necessary to achieve breast symmetry, and is therefore covered when both implants are removed at the same time.

In addition, when a individual has been diagnosed with unilateral breast implant-associated anaplastic large cell lymphoma (BIALCL), removal of both implants (affected and the contralateral breast) is considered medically necessary and is therefore covered regardless of why the implants were originally placed.

The following criteria were added to the policy for the removal of saline-filled breast implants to address the contralateral (unaffected) breast:

When the above criteria for removal of a saline-filled breast implant are met unilaterally AND the implant was originally placed for a medically necessary indication (e.g., chest wall deformities such as Pectus Excavatum or Poland’s Syndrome, repair of breast asymmetry due to a medically necessary mastectomy or lumpectomy, repair of breast asymmetry due to trauma), then removal of the implant in the contralateral breast is considered medically necessary to achieve breast symmetry, and is therefore covered when both implants are removed at the same time.

In addition, when a individual has been diagnosed with unilateral breast implant-associated anaplastic large cell lymphoma (BIALCL), removal of both implants (affected and the contralateral breast) is considered medically necessary and is therefore covered regardless why the implants were originally placed.

The following ICD- 10CM codes have been added to this policy:

C84.60 Anaplastic large cell lymphoma, ALK-positive, unspecified site
C84.61 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of head, face, and neck
C84.62 Anaplastic large cell lymphoma, ALK-positive, intrathoracic lymph nodes
C84.63 Anaplastic large cell lymphoma, ALK-positive, intra-abdominal lymph nodes
C84.64 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of axilla and upper limb
C84.65 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of inguinal region and lower limb
C84.66 Anaplastic large cell lymphoma, ALK-positive, intrapelvic lymph nodes
C84.67 Anaplastic large cell lymphoma, ALK-positive, spleen
C84.68 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of multiple sites
C84.69 Anaplastic large cell lymphoma, ALK-positive, extranodal and solid organ sites
C84.70 Anaplastic large cell lymphoma, ALK-negative, unspecified site
C84.71 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of head, face, and neck
C84.72 Anaplastic large cell lymphoma, ALK-negative, intrathoracic lymph nodes
C84.73 Anaplastic large cell lymphoma, ALK-negative, intra-abdominal lymph nodes
C84.74 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of axilla and upper limb
C84.75 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of inguinal region and lower limb
C84.76 Anaplastic large cell lymphoma, ALK-negative, intrapelvic lymph nodes
C84.77 Anaplastic large cell lymphoma, ALK-negative, spleen
C84.78 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of multiple sites
C84.79 Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites
Z48.3 Aftercare following surgery for neoplasm

Revisions From 11.08.14j:

10/01/2018

This version of the policy will become effective 10/01/2018. The following ICD-10 codes have been added to the policy: T81.40XA, T81.40XD, T81.40XS, T81.41XA, T81.41XD, T81.41XS, T81.42XA, T81.42XD, T81.42XS, T81.43XA, T81.43XD, T81.43XS, T81.44XA, T81.44XD, T81.44XS, T81.49XA, T81.49XD, T81.49XS. The following ICD-10 codes have been termed from the policy:T81.4XXA, T81.4XXD, T81.4XXS.

Revisions From 11.08.14i:

04/25/2018

This policy has undergone a routine review, and no revisions have been made.

Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date:

10/1/2025

Version Issued Date:

10/1/2025

Version Reissued Date:

4/29/2026