Breast Implant Removal
Customize your policy alerts
Sign up for Aetna Policy 0142 alerts
Get alerted when Policy 0142 changes without checking for updates manually.
Monitor payer policy activity
Clinical coverage policy describing when removal of breast implants (with capsulectomy or capsulotomy as applicable) is considered medically necessary, cosmetic, limited, or not medically necessary for Aetna members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Breast Implant Removal
Medical Necessity — Primary Indications
Covered when ANY of the following are met for members (cosmetic augmentation, reconstruction after medically necessary mastectomy, or augmentation for gender dysphoria):
From policy medical necessity list.
Medical Necessity — Reconstruction-specific Indications
Additional medically necessary indications when reconstruction followed a medically necessary mastectomy or augmentation for gender dysphoria:
These are additional criteria specific to reconstructed breasts. Photographic documentation of contracture may be required; if unilateral criteria are met, bilateral removal when performed at the same time is considered medically necessary.
Cosmetic
Cosmetic stance:
Re-insertion of new breast implants after removal for medical indications is considered cosmetic if the original implant was cosmetic.
Removal of a ruptured saline-filled breast implant is not considered medically necessary when the implant was originally placed for cosmetic augmentation. The policy explicitly states that Aetna considers removal of ruptured saline-filled breast implants not medically necessary for members who previously underwent cosmetic breast augmentation mammoplasty. Providers should therefore expect such requests to be denied unless another listed medical necessity criterion applies.
For reconstructed breasts (implantation following a medically necessary mastectomy or augmentation for gender dysphoria), different reconstruction-specific indications apply (e.g., Baker Class III contracture or extra-capsular saline rupture that compromises cosmetic outcome). Photographic documentation of contracture may be required when evaluating requests in those reconstructed cases.
IgG antibody testing in connection with silicone breast implants is not considered medically necessary. The policy specifies that development of IgG antibodies is neither specific to silicone implants nor indicative of autoimmune disorders, and therefore Aetna does not consider IgG testing for this purpose medically necessary.
Separately, removal of silicone implants for autoimmune disease is not considered medically necessary unless the member meets at least one of the policy's listed selection criteria (for example, rupture of a silicone gel–filled implant or another primary medical indication).
Coding and Related Clinical Notes
| 19325 | Mammoplasty, 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. |
| 19370 | Open periprosthetic capsulotomy, breast. |
| 19371 | Periprosthetic capsulectomy, breast. |
| 15769 | Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia). |
| 15771 | Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate. |
| 15772 | each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure). |
| 15773 | Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate. |
| 15774 | each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure). |
| 19120-19126 | Breast, excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, one or more lesions. |
| 19316-19380 | Breast, repair and/or reconstruction procedures. |
| L8020-L8039 | Breast prostheses. |
| L8600 | Implantable breast prosthesis, silicone or equal. |
| C50.011-C50.929 | Malignant neoplasm of breast. |
| C84.60-C84.69 | Anaplastic large cell lymphoma, ALK-positive. |
| C84.70-C84.79 | Anaplastic large cell lymphoma, ALK-negative. |
| F64.0-F64.9 | Gender identity disorders. |
| N63.0-N63.42 | Unspecified lump in breast. |
| N64.4 | Mastodynia. |
| R52 | Pain, unspecified. |
| T85.41x+-T85.49x+ | Mechanical complication of breast prosthesis and implant. |
| T85.79x+ | Infection and inflammatory reaction due to other internal prosthetic devices, implants, or grafts. |
Provider Actions and Authorization Guidance
Codes contingent on meeting selection criteria
Coverage of the listed CPT, HCPCS and ICD-10 codes is contingent on meeting the policy's selection criteria; the policy lists specific codes that are covered only if medical necessity criteria are satisfied.
- Covered CPT codes if selection criteria met: 19325, 19328, 19330, 19340, 19342, 19370, 19371.
- CPT codes noted as not covered for indications in this CPB: 15769, 15771, 15772, 15773, 15774.
- Other related CPT ranges: 19120-19126; 19316-19380.
- HCPCS: L8020-L8039; L8600.
- ICD-10 codes covered if selection criteria met include C50.011-C50.929, C84.60-C84.69, C84.70-C84.79, F64.0-F64.9, N63.0-N63.42, N64.4, R52, T85.41x+-T85.49x+, T85.79x+.
Prior authorization: consult full policy/benefit
The excerpt does not specify code-level prior authorization requirements; providers should check the member's benefit plan or complete policy for any prior authorization rules that apply to these procedures and codes.
- Consult the complete policy and the member's benefit plan to determine whether prior authorization is required for any CPT/HCPCS/ICD-10 codes listed in this policy.
Try conservative treatments before explantation for hypersensitivity-like reactions
Conservative therapy should be attempted for cutaneous hypersensitivity–like reactions associated with breast implants before considering explantation; examples include antibiotics, oral corticosteroids, and topical corticosteroids.
- Explantation may be considered only after failure of conventional treatments such as antibiotics, oral corticosteroids, and topical corticosteroids.
Infection pathway: trial antibiotics → salvage → explantation as indicated
Management of infected implants may start with a trial of antibiotics for mild infections, proceed to surgical salvage when indicated, or result in explantation depending on severity and response; published evidence shows some mild infections respond to antibiotics alone while others require surgical intervention or removal.
- In systematic review data, ~29% of patients with mild infection were treated exclusively with antibiotics, with ~81% success.
- Surgical salvage was attempted in ~39% with ~85% success in retaining implants.
- Explantation occurred in ~35% of cases; a minority later had re‑implantation.
Document contracture photographically; bilateral removal allowed when unilateral criteria met
Photographic documentation of capsular contracture may be required for medical review; if unilateral criteria for removal are met, removal of the contralateral implant at the same operative session is considered medically necessary.
- Photographs may be requested to document Baker class contracture.
- If criteria are met for one breast, bilateral removal with capsulectomy/capsulotomy at the same time is medically necessary.
Policy metadata and review dates for administrative processing
Reference the policy's administrative metadata (effective date 07/11/1996; last review 03/28/2023; next review 02/08/2024) when processing requests and appeals to ensure use of the current policy version.
- Effective date: 07/11/1996.
- Last review: 03/28/2023.
- Next review: 02/08/2024.
Denial risk: Baker Class III (non‑reconstruction) and certain removal indications
Removal requests for Baker Class III contracture that do not follow a medically necessary mastectomy are subject to medical review and may be denied; implant removal for biopsy of a breast mass not proven malignant or removal for mastectomy/lumpectomy that can be done with the implant in place are also subject to medical review and may be denied.
- Baker Class III contracture requests not following a medically necessary mastectomy are reviewable and may be denied.
- Implant removal for biopsy of a breast mass not proven cancerous may be denied.
- Requests to remove an implant when the mastectomy or lumpectomy could be performed with the implant in place may be denied.
Administrative note: policy history present; prior authorization details not specified here
Administrative note: this policy excerpt shows policy status and review history but does not state explicit prior authorization requirements; verify code-level authorization rules with the full policy or the member's benefit plan.
- Policy status available; absence of explicit prior authorization language in this excerpt.
- Providers must confirm authorization requirements elsewhere as needed.
Background and Clinical Context
Silicone implant rupture may be classified as intracapsular or extracapsular. An intracapsular rupture denotes silicone gel contained within the fibrous capsule surrounding the implant, whereas an extracapsular rupture involves silicone gel extruded beyond the capsule, which may induce granulomatous reactions or migrate to regional lymph nodes.
Clinically, extracapsular rupture is more likely to produce observable symptoms or changes and is therefore regarded as an indication for explantation when it leads to clinical problems. The policy reflects this distinction by listing intra- or extracapsular rupture of silicone gel–filled implants among the primary indications for medically necessary removal, while noting reconstruction-specific allowance for extra-capsular saline rupture when it compromises cosmetic outcome.
Definitions and Classifications
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.