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Printer Friendly Version Breast Implant Removal

Breast Implant Removal

DESCRIPTION

Breast implants are prosthesis used for post-surgical mastectomy reconstruction. Breast implants are also used for breast enlargement for primarily cosmetic reasons. They may be internally placed or worn externally in the clothing. For internal use, the breast implant is placed into the breast area once the natural breast tissue has been removed. If a patient has adverse reactions to the implants, the implants must be removed.

POLICY

Removal of breast implants is covered only when original implants were placed for a non-cosmetic reason, and only when medically necessary due to one of the following:

Infection
Complications of leakage
Suspected or actual rupture

Removal of breast implants is not covered, regardless of medical necessity, when implants were placed for cosmetic reasons.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

POLICY HISTORY

7/1993: Approved by Medical Policy Advisory Committee (MPAC)

2/1998: Revision approved by Medical Policy Advisory Committee (MPAC)

5/15/2001: Description section and content added

4/18/2002: Type of Service and Place of Service deleted

10/14/2004: Code Reference section reviewed, no changes

1/7/2009: Policy reviewed, no changes

05/06/2013: Policy reviewed; no changes.

SOURCE(S)

Blue Cross Blue Shield Association policy #7.01.22

CODE REFERENCE

This is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes

Code Number	Description
CPT-4
19328	Removal of intact mammary implant
19330	Removal of mammary implant material
ICD-9 Procedure
85.94	Removal of implant of breast
ICD-9 Diagnosis
996.54	Mechanical complications due to breast prosthesis
996.69	Infection and inflammatory reaction due to breast prosthesis
HCPCS

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