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Removal of Breast Implants
MA11.076h

Policy

This policy uses coverage criteria primarily based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents. In the absence of fully established coverage criteria from these Medicare coverage documents for a specific medical service or item, the criterion/indication/service indicated by an asterisk below (*) is based on internal coverage criteria developed by the Company in consideration of peer-reviewed medical literature, clinical practice guidelines, regulatory status, and/or expert opinion. ​

MEDICALLY NECESSARY

The removal of breast implant(s) is considered medically necessary and, therefore, covered for the following indications:
  • Documented broken or failed implants
  • Extrusion
  • Infection or rejection
  • Siliconoma or granuloma
  • Interference with diagnosis of breast cancer
  • Surgical treatment of breast cancer
  • Painful capsular contracture with disfigurement
  • Individuals diagnosed with breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)* (NCCN, 2026; ASPS, 2024)​
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 an individual has been diagnosed with unilateral breast implant–associated anaplastic large cell lymphoma (BIA-ALCL), 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.

NOT COVERED

Requests for removal of breast implant(s) that do not meet the medical necessity criteria listed in this policy are considered cosmetic services. Services that are cosmetic are not covered by the Company because cosmetic services are not covered by Medicare. 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 not covered by the Company because cosmetic services are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

WOMEN'S HEALTH AND CANCER RIGHTS ACT (WHCRA)

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

  • All stages of reconstruction of the breast on which the mastectomy has been performed;
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
  • Prostheses and physical complications of mastectomy, including lymphedemas.
REQUIRED DOCUMENTATION

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

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, the removal of breast implant(s) is covered under the medical benefits of the Company's Medicare Advantage 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 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 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.

CLINICAL BENEFITS OF INTERNALLY DEVELOPED COVERAGE CRITERIA ​
In accordance with federal regulations, the plan has determined that the use of this additional criterion is necessary to interpret or supplement Medicare's criteria and that it provides clinical benefits that are highly likely to outweigh any clinical harms, including from delayed or decreased access to items or services, because of the increased risk of BIA-ALCL caused by textured breast implants. 

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). Aesthet Surg J. 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-lymphom​a-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


Coding and Billing Requirements

Policy History

Revisions From MA11.076h:
​04/29/2026
​This policy has been reviewed and reissued to communicate the Company’s continuing position on removal of breast implants. ​
10/01/2025Inclusion 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 MA11.076g:
​07/09/2025
​This policy has been reissued in accordance with the Company's annual review process.​
​05/29/2024​
​This policy has been reissued in accordance with the Company's annual review process.
01/01/2024

​Effective 01/01/2024, this policy applies to New Jersey Medicare Advantage (MA) lines of business.
06/05/2023
This version of the policy will become effective 06/05/2023.

The following policy language was removed from this policy:

However, reconstruction or replacement of an implant requiring removal for any of the above indications that was originally placed for reconstruction of a traumatic or surgically created breast deficit will be covered as medically necessary.​

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

The following ICD-10 Diagnosis codes have been added to this policy: C50.911, N61.20, ​N61.21, N61.22, N61.23​

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

Revisions From MA11.076f:
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 MA11.076e:
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 ​MA11.076d:
06/08/2019This 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 breast implant removal on the contralateral side.

The following indication was added to this policy for the removal of breast implant(s):
  • Individuals diagnosed with breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)
The following criteria were added to the policy to address breast implant removal on the contralateral side:
  • 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 why the implants were originally placed.
The following ICD-10 CM codes have been added to this policy:

C84.60 C84.61 C84.62 C84.63 C84.64
C84.65 C84.66 C84.67 C84.68 C84.69
C84.70 C84.71 C84.72 C84.73 C84.74
C84.75 C84.76 C84.77 C84.78 C84.79
Z44.30 Z90.10 Z90.11 Z90.12 Z90.13

Revisions From MA11.076c:
04/25/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on the removal of breast implants.
03/29/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on removal of breast implants
10/01/2016This policy has been identified for the ICD-10 code update, effective 10/01/2016.
Deleted:
T85.81XA, T85.81XD, T85.81XS, T85.82XA, T85.82XD, T85.82XS, T85.83XA, T85.83XD, T85.83XS, T85.84XA, T85.84XD, T85.84XS

Added:
T85.818A, T85.818D, T85.818S, T85.828A, T85.828D, T85.828S, T85.838A, T85.838D, T85.838S, T85.848A, T85.848D, T85.848S

Revisions From MA11.076b:
03/30/2016This version of the policy will become effective on 04/06/2016.

This policy was updated to delineate the Company's coverage criteria for the Removal of Breast Implants.

Revisions From MA11.076a:
11/04/2015This version of the policy will become effective on 11/18/2015.

The intent of this policy remains unchanged; however, the policy has been updated to further clarify coverage criteria for removal of breast implants.

Revisions From MA11.076:
01/01/2015This is a new policy.

10/1/2025
10/1/2025
4/29/2026
MA11.076
Medical Policy Bulletin
Medicare Advantage
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.