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DESCRIPTIONBreast 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.
POLICYRemoval 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:
Removal of breast implants is not covered, regardless of medical necessity, when implants were placed for cosmetic reasons.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY7/1993: 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 REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.