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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyBCBS North Dakota Breast Surgery Coverage | OpenPa…
    Ask Trek AI about this page
    CurrentBlue Cross Blue Shield - North DakotaPolicy N/A

    Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants

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    This policy governs medical-necessity criteria, documentation, and coding for reconstructive breast surgery, symmetry procedures, mastopexy, breast implant explantation or replacement, and related breast reconstruction services, subject to applicable contract terms and exclusions.

    Policy Summary
    PayerBlue Cross Blue Shield - North Dakota
    PolicyReconstructive Breast Surgery/Mastopexy, and Management of Breast Implants
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOctober 1, 2026
    Last ReviewAug 1, 2026
    Next Review DateAugust 1, 2027
    Key ActionSubmit history and physical examination or chart notes for review.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Recognized implant-associated malignancies

    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.

    2Primary reconstructive indications
    1998WHCRA basis
    33Listed procedure codes

    Medical Necessity and Coverage Criteria

    Reconstruction of a Diseased or Injured Breast

    Reconstructive breast surgery of a diseased or injured breast may be considered medically necessary when ALL of the following are met:

    ALL of the following

    • ONE of the following

      • The surgery is performed after prophylactic or therapeutic mastectomy.
      • The surgery is performed after accidental injury or trauma to the breast resulting in significant malformation.
    • The treating physician recommends the reconstructive surgery as medically necessary.

    Surgery on the Unaffected Breast for Symmetry

    Reconstructive surgery on an unaffected breast to achieve symmetry may be considered medically necessary when ALL of the following are met:

    ALL of the following

    • The contralateral diseased or injured breast underwent reconstruction that was medically necessary under the policy criteria.
    • The treating physician recommends surgery on the unaffected breast to achieve symmetry.

    Explantation or Replacement of a Reconstructive Implant

    Breast implant explantation and/or replacement may be considered medically necessary when ALL of the following are met:

    ALL of the following

    • The implant(s) was/were placed during reconstructive breast surgery that was medically necessary under the policy criteria.
    • Documentation of the original indication for implantation is submitted.
    • If explantation is unilateral or bilateral, the applicable explantation is performed during the same procedure.

    Explantation for Implant-Associated Malignancy

    Breast implant explantation may be considered medically necessary when ALL of the following are met:

    ALL of the following

    • Pathologic confirmation of ONE of the following

      • Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).
      • Breast implant-associated squamous cell carcinoma (BIA-SCC).
    • The pathologic confirmation is based on pre-operative percutaneous needle aspiration of a seroma or needle biopsy of a mass, if present.

      Imaging modalities suggesting breast implant-associated malignancy are not sufficient.

    Cosmetic Breast Revision

    Breast revision surgery, including breast implant explantation and/or replacement, is considered cosmetic when ANY of the following applies:

    ANY of the following

    • The procedure follows a cosmetic primary breast procedure.
    • One or more medical-necessity criteria for reconstructive breast surgery, symmetry surgery, reconstructive implant explantation or replacement, or implant-associated malignancy explantation is not met.

    Cosmetic Mastopexy

    Mastopexy is considered cosmetic when ANY of the following applies:

    ANY of the following

    • The applicable medical-necessity criteria for reconstructive breast surgery are not met.
    • The applicable medical-necessity criteria for surgery on an unaffected breast to achieve symmetry are not met.
    • The applicable medical-necessity criteria for reconstructive breast implant explantation and/or replacement are not met.

    This policy does not address procedures related to gender-affirming interventions for gender dysphoria. See the applicable Cross References for the policy that governs those procedures.

    Coverage is subject to the applicable member contract. Contract language takes precedence over this Medical Policy. Contracts exclude services or procedures considered investigational or cosmetic, and providers may bill members for those services. Providers are encouraged to inform members before rendering such services that they may be financially responsible.

    Breast revision surgery, including implant explantation and/or replacement, following a cosmetic primary breast procedure is cosmetic when the applicable medical-necessity criteria are not met.

    Mastopexy is cosmetic when the applicable reconstructive or symmetry medical-necessity criteria are not met.

    Reconstructive Breast Surgery Coding

    Listed reconstructive breast surgery codesmixedCovered
    11920Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq. cm or less
    11921Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm
    11970Replacement of tissue expander with permanent implant
    11971Removal of tissue expander(s) without insertion of implant
    15769Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)
    15771Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate
    15772Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof
    19316Mastopexy
    19318Breast reduction
    19325Breast augmentation with implant
    1–10 of 32
    1/4
    Codes not reported for breast fat graftingCPT
    11950Subcutaneous injection of filling material (eg, collagen)
    11951Subcutaneous injection of filling material (eg, collagen)
    11952Subcutaneous injection of filling material (eg, collagen)
    11954Subcutaneous injection of filling material (eg, collagen)
    19366Breast flap graft, other technique
    19380Revision of reconstructed breast
    19499Unlisted procedure, breast

    Documentation and Review Requirements

    Documentation Required

    History and Physical or Chart Notes Required

    Submit history and physical examination documentation or chart notes for review. Missing clinical documentation may affect the review and coverage decision.

    Documentation Required

    Pathologic Confirmation Required

    For implant explantation requested بسبب implant-associated malignancy, submit pathologic confirmation of BIA-ALCL or BIA-SCC.

    • Pathologic confirmation may come from pre-operative percutaneous needle aspiration of a seroma or needle biopsy of a mass, if present.
    Documentation Required

    Document Original Implant Indication

    For explantation of an implant placed during medically necessary reconstruction, document the original indication for implantation.

    Policy Background

    Reconstructive breast surgery restores the normal appearance of a breast after mastectomy, surgery, accidental injury, or trauma. Cosmetic breast surgery alters or enhances the appearance of a breast that has not been significantly changed by surgery, accidental injury, or trauma. Reconstruction may involve implants, tissue expanders, autologous tissue flaps, nipple or areola reconstruction, tattooing, fat grafting, or procedures on the opposite breast to achieve symmetry. The policy reflects the Women's Health and Cancer Rights Act of 1998, which addresses reconstruction of the mastectomy breast, contralateral symmetry, prostheses, and physical complications of mastectomy.

    Key Definitions

    Mastectomy
    DefinitionMastectomy is defined as complete or partial removal of the breast.
    Complete procedureComplete mastectomy is included.
    Partial procedurePartial mastectomy is included, including lumpectomy.
    Reconstructive breast surgery
    DefinitionReconstructive breast surgery consists of surgical procedures intended to restore the normal appearance of the breast.
    After surgeryThe restoration may be performed after surgery.
    After injury or trauma
    Policy Summary
    PayerBlue Cross Blue Shield - North Dakota
    PolicyReconstructive Breast Surgery/Mastopexy, and Management of Breast Implants
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOctober 1, 2026
    Last ReviewAug 1, 2026
    Next Review DateAugust 1, 2027
    Key ActionSubmit history and physical examination or chart notes for review.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaReconstructive Breast Surgery CodingDocumentation and Review RequirementsPolicy BackgroundKey Definitions
    Documentation Required

    Treating Physician Recommendation Required

    Document the treating physician’s recommendation for reconstructive breast surgery or surgery on an unaffected breast to achieve symmetry with the contralateral breast.

    Denial Risk

    Cosmetic Primary Procedure or Unmet Criteria

    Breast revision surgery, including implant explantation or replacement, following a cosmetic primary breast procedure is considered cosmetic when applicable medical-necessity criteria are not met.

    Denial Risk

    Mastopexy Without Reconstructive Indication

    Mastopexy is considered cosmetic when the medical-necessity criteria for reconstruction or symmetry are not met.

    Denial Risk

    Imaging Alone Does Not Confirm Malignancy

    Imaging findings suggesting breast implant-associated malignancy are not sufficient to establish coverage for implant explantation. Submit pathologic confirmation of BIA-ALCL or BIA-SCC as specified in the required documentation.

    Billing Rule

    Apply Contractual Limitations and Exclusions

    Apply the member’s contract when reviewing coverage. Contract language takes precedence over this policy when there is a conflict, and contractual limitations or exclusions may apply to reconstructive and cosmetic procedures, pre-existing conditions, and complications of non-covered procedures.

    • Contracts exclude, among other services, procedures considered investigational or cosmetic.
    • Providers may bill members for investigational or cosmetic services and should inform members before services are rendered that they may be financially responsible.
    • Contractual limitations and exclusions may apply to illnesses or conditions initially occurring before coverage and to complications of non-covered procedures not otherwise specified.
    The restoration may be performed after accidental injury or trauma.
    Cosmetic breast surgery
    DefinitionCosmetic breast surgery is intended to alter or enhance the appearance of a breast.
    Breast appearanceIt applies when the breast does not have a significantly altered appearance.
    Exclusions from the definitionThe breast does not have a significantly altered appearance due to surgery, accidental injury, or trauma.