Effective April 15, 2026, Cigna clarified coverage for removal and capsule surgery of saline and silicone breast implants, specifying when explantation is medically necessary versus cosmetic. Explantation and capsular procedures are covered when related to breast reconstruction, confirmed silicone rupture/extrusion on imaging, interference with cancer diagnosis/treatment, infection unresponsive to medical therapy, implant exposure, Baker Grade IV contracture, tissue necrosis, BIA-ALCL/BIA-SCC, or use of Allergan BIOCELL textured devices. Removal of intact silicone implants solely for suspected autoimmune disease, breast implant illness, or cancer prevention, as well as replacement or mastopexy for cosmetic reasons, are considered not medically necessary. The policy reiterates that saline ruptures alone are typically cosmetic unless other indications exist and that MRI may be required to confirm silicone rupture when other imaging is inconclusive.
April 15, 2026 Revision: Clarified Indications and Not Medically Necessary Criteria
This revision, effective 4/15/2026, clarifies and revises coverage statements related to removal and replacement of breast implants. Key stated revisions include updated policy language for removal of either saline-filled or silicone gel-filled implants when associated with breast reconstruction, clarified indication requirements for removal of a silicone gel-filled implant (specifically documentation of rupture and/or extrusion on imaging), and explicit delineation of situations considered not medically necessary or cosmetic (for example, removal solely for suspected autoimmune disease or breast implant illness). The document also notes prior annual reviews and indicates the latest substantive changes occurred in the April 15, 2026 annual review cycle.
Medically Necessary Indications for Explantation and Capsular Surgery
The policy defines when removal of breast implants and associated capsular procedures are considered medically necessary. Removal of either saline-filled or silicone gel-filled implants and surgical management of the implant capsule (capsulotomy, capsulorrhaphy, partial or complete capsulectomy) is medically necessary when associated with breast reconstruction following mastectomy or lumpectomy, including to achieve symmetry of the nondiseased breast. For silicone gel-filled implants, removal (with or without capsulectomy) is medically necessary when rupture and/or extrusion of implant contents have been confirmed on imaging such as mammography, ultrasound, or MRI.
Additionally, removal of either saline or silicone implants is medically necessary if at least one listed indication is met, including interference with diagnostic evaluation or treatment of breast cancer, acute/persistent or recurrent infection unresponsive or intolerant to medical management, current exposure of the implant, Baker Grade IV capsular contracture, tissue necrosis, confirmed diagnoses of BIA-ALCL or BIA-SCC, or current use of Allergan BIOCELL textured implants and tissue expanders.
Not Medically Necessary and Cosmetic Exclusions
The policy specifies circumstances considered not medically necessary or cosmetic. Removal of an intact silicone gel-filled implant solely for suspected autoimmune/connective tissue disease, breast implant illness, or breast cancer prevention is considered not medically necessary. Likewise, removal of a ruptured saline implant in the absence of one of the policy's covered indications is not medically necessary. The policy lists additional noncovered/cosmetic reasons for removal, including procedures performed solely to treat psychological symptoms, solely to improve appearance, solely because of implant shifting or migration, removal of a contralateral implant absent other indications, and replacement of an implant following removal. The policy also explicitly states that mastopexy following implant removal is considered not medically necessary/cosmetic unless performed as part of reconstruction following mastectomy or lumpectomy.
These delineations separate clinically warranted explantation (e.g., infection, confirmed rupture of silicone implants, BIA-ALCL) from procedures driven by cosmetic or solely symptomatic complaints without supporting clinical indications documented in the policy.
Clinical Context: Rupture, Capsular Contracture, Imaging, and BII Evidence
The policy provides clinical background relevant to decision-making around explantation. It reiterates that breast implants are class III FDA-regulated devices and are not lifetime devices; implants may rupture or deflate over time, with saline ruptures typically causing cosmetic change but not requiring removal unless other indications exist. For silicone gel-filled implants, rupture may be intracapsular or extracapsular, and MRI may be medically necessary to confirm silicone gel rupture when mammography or ultrasound cannot. The document summarizes Baker grading for capsular contracture and specifies that clinically significant contracture corresponding to Baker Grade IV is an indication for treatment up to capsulectomy or implant removal.
The background also reviews epidemiologic evidence and systematic reviews cited in the policy, noting that prior large studies and reviews found no causal association between implants and connective tissue disease or increased breast cancer risk, while acknowledging recent literature on breast implant illness that reports symptom prevalence and inconsistencies across studies. This context underpins the policy’s stance that explantation of intact silicone implants solely for systemic symptom complaints is considered not medically necessary.
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