Breast implant removal and/or replacement
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Policy governing medical necessity determinations for surgical removal and/or replacement of breast implants (silicone or saline) for Commercial and Medicare lines of business; guidance is for Utilization Management Coordinator Registered Nurses and reviewers.
No material clinical or coverage changes in this revision.
Coverage Criteria
Coverage determinations for breast implant removal and/or replacement are governed first by the member's specific benefit contract and applicable law. Contract language as well as state and federal laws take precedence over any medical policy. Reviewers must consult the member's Network Health coverage documents (for example, the Certificate of Coverage, Evidence of Coverage, or Summary Plan Description) because coverage may differ by plan and eligibility is determined by those contractual terms.
For Medicare members, applicable CMS coverage statements — including National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) — apply and should be referenced when making medical necessity decisions. Network Health medical policies are guidance documents and do not replace the judgment of the reviewing medical director or dictate clinical practice.
Provider Actions and Prior Authorization
Prior authorization and coverage determination
Determinations regarding medical necessity for breast implant removal and/or replacement are made by UMC staff after consulting the member's individual coverage document and, for Medicare members, applicable CMS coverage statements.
Check member coverage before review
UMC staff must consult the member's Certificate of Coverage, Evidence of Coverage, or Summary Plan Description prior to applying medical necessity criteria for Commercial members.
- Consult the member's individual coverage document before applying medical necessity criteria
Consult member's individual coverage document
UMC staff must review the member's individual coverage document (Certificate of Coverage, Evidence of Coverage, Summary Plan Description) and follow CMS NCD/LCD statements for Medicare members when determining coverage.
- Use the member's specific Network Health coverage document to determine contractual benefits
- For Medicare members, follow applicable CMS National or Local Coverage Determinations (NCD/LCD)
Coverage subject to contract and law
Contract language and state and federal laws take precedence over this medical policy; coverage may differ by plan and requests may be denied if the service is not included in the member's benefit plan.
- Network Health coverage documents outline contractual terms and are considered first in determining eligibility
- Medicare membership follows CMS coverage statements (NCD/LCD)
Background
Breast implant removal and/or replacement refers to the surgical removal of existing silicone or saline implants. This policy exists to guide Utilization Management Coordinator (UMC) staff and clinical reviewers in assessing medical necessity for these procedures and to ensure determinations align with the member's benefit contract and, for Medicare members, applicable CMS coverage statements.
UMC staff must consult the member's individual coverage document prior to applying medical necessity criteria. Because Network Health policies are advisory, reviewers should also recognize that policies are periodically updated as medical technologies evolve and that documentation of brand names in a policy is for reference only.
Definitions
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