ModifiedEmblemHealthPolicy MG.MM.SU.14jC

Breast Implants and Reconstruction

Clinical coverage criteria for breast augmentation, reconstruction, implant removal, and related procedures for EmblemHealth members; defines medical necessity, documentation, coding, limitations, and exclusions for providers and prior authorization reviewers.

Policy Summary

PayerEmblemHealth

PolicyBreast Implants and Reconstruction

Policy CodePolicy MG.MM.SU.14jC

Change TypeCoverage and exclusion updatescoding/billing redirects

Effective Date

Next Review Date

Key ActionSubmit clinical evidence and imaging (including noncontrast MRI when applicable) to support medical necessity for implant removal, capsulectomy, reinsertion, or replacement.

SourceLink

POLICY UPDATE CHANGES

Added not pertaining to HCPCS codes S2066, S2067, and S2068 redirecting users to applicable Reimbursement Policy.

Transferred policy content to individual company branded template.

Removed language communicating that a capsulectomy is not medically necessary for saline implant removal.

Added language that 'Breast implant illness' or 'silicone implant illness' are not medically necessary indications for implant removal and removal of textured implants due to fear of BIA-ALCL is not medically necessary.

Added positive-coverage language for fat grafting (removing investigational designation).

Added information pertaining to New York State Chest Wall Reconstruction Bill no S07881 and billing instructions aligned with AMA breast repair/reconstruction guidelines.

Added language pertaining to tissue transfer, lumpectomy and nipple-sparing to section delineating reconstruction procedures and added 'noncontrast' to MRI within footnote delineating the best noninvasive test for silicone implant rupture.

Amended Limitations/Exclusions to communicate that removal of ruptured saline implants is not medically necessary.

~50+Codes listed

noncontrast MRI

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Preferred test for silicone rupture

Documentation requiredAuthorization needs

Coverage Criteria and Limitations

Covered When Criteria Met

Covered Procedures and Conditions

Implant removal indications: extrusion; infection; objective evidence of rupture (mammogram/MRI/ultrasound); Baker IV capsular contracture (photos required).

Coverage, Limitations, and Documentation

Prior authorization must accompany requests for implant removal except in emergent situations.

Documentation checklist: clinical history; imaging confirming rupture when claimed; photos for Baker IV; operative reports if prior surgery relevant.

Denial Risk

Not Medically Necessary Indications — Denial Risk

Requests for implant removal citing "breast implant illness" or "silicone implant illness," removal of saline implant rupture, or removal of textured implants solely due to fear of BIA-ALCL carry a high risk of denial under this policy.

Do not submit implant removal prior authorization requests solely for breast implant illness / silicone implant illness—these are not medically necessary per policy.
Removal of ruptured saline implants is specifically listed as not medically necessary—expect denial unless other covered indications are documented.
Removal of textured implants solely for fear of BIA-ALCL is not a covered indication.

CPT/HCPCS/ICD-10 Codes and Classifications

Procedure and HCPCS/CPT codesCPTCovered

11920	Tattooing, intradermal introduction of insoluble opaque pigments; 6.0 sq cm or less
11921	Tattooing; 6.1 to 20.0 sq cm
11922	Tattooing; each additional 20.0 sq cm
15734	Muscle, myocutaneous, r fasciocutaneous trunk flap
15756	Free muscle or myocutaneous with microvascular anastomosis flap
15769	Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)
15771	Autologous fat grafting (referenced in limitations)
15772	Autologous fat grafting (referenced in limitations)
19303	Mastectomy, simple, complete
19316	Mastopexy

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ICD-10 diagnosis codesICD-10

C50.011	Malignant neoplasm of nipple and areola, right female breast
C50.012	Malignant neoplasm of nipple and areola, left female breast
C50.019	Malignant neoplasm of nipple and areola, unspecified female breast
C50.111	Malignant neoplasm of central portion of right female breast
C50.112	Malignant neoplasm of central portion of left female breast
C50.119	Malignant neoplasm of central portion of unspecified female breast
C50.211	Malignant neoplasm of upper-inner quadrant of right female breast
C50.212	Malignant neoplasm of upper-inner quadrant of left female breast
C50.219	Malignant neoplasm of upper-inner quadrant of unspecified female breast
C50.311	Malignant neoplasm of lower-inner quadrant of right female breast

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HCPCS codes referencedHCPCS

S2066	HCPCS code referenced — redirect to Reimbursement Policy
S2067	HCPCS code referenced — redirect to Reimbursement Policy
S2068	HCPCS code referenced — redirect to Reimbursement Policy

Baker Classification — Capsular contracture grading (I–IV)

Baker IAugmented breast feels soft as a normal breast.

Baker IIAugmented breast is less soft; the implant can be palpated but is not visible.

Baker IIIAugmented breast is firm and palpable and the implant or distortion is visible.

Baker IVAugmented breast is hard, painful, cold, tender and distorted.

Noninvasive test for silicone gel implant rupture

Preferred noninvasive testNoncontrast MRI is cited as the best noninvasive test for silicone gel implant rupture.

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior authorization required with clinical evidence and imaging

Preauthorization is required for implant removal, capsulectomy/capsulotomy, reinsertion, or replacement; submit clinical evidence and relevant imaging to support medical necessity.

Include imaging when rupture is alleged (mammography, MRI, or ultrasonography).

Billing Rule

Prior authorization and billing guidance; state law applicability

Follow applicable state law and EmblemHealth billing guidance; providers should follow EmblemHealth reimbursement policy for HCPCS codes S2066–S2068 as redirected in the policy.

Billing instructions aligned with AMA breast repair/reconstruction guidelines are referenced in revision history.

Key Definitions

Breast reconstruction — definition and covered indications

DefinitionBreast reconstruction is a surgical procedure that restores the natural breast contour and mass following mastectomy, trauma, injury, or congenital deformity.

Indications coveredReconstruction following mastectomy, reconstruction of the contralateral breast for symmetry, and reconstruction after traumatic injury are covered when criteria are met.

Techniques includedReconstruction modalities addressed include tissue expansion with implant insertion, autologous flap transfer, and autologous fat grafting.

Related provisionsFederal law (Women’s Health and Cancer Rights Act of 1998) requires coverage for reconstruction and treatment of physical complications after mastectomy.

Capsular contracture / Baker Classification — definition and grading

Background and Scope

Breast reconstruction procedures restore breast contour and mass after mastectomy, trauma, or congenital deformity and may employ implants (silicone or saline), tissue expanders, autologous flap transfer, or autologous fat grafting. The policy covers reconstruction of the affected breast and, when indicated by law or reconstructive need, surgery of the contralateral breast for symmetry as required by the Women’s Health and Cancer Rights Act.

Implants can be associated with local complications such as capsular contracture (graded by the Baker Classification) and implant rupture. The guideline distinguishes between medically necessary indications for implant removal—such as extrusion, documented rupture with appropriate imaging, infection, or Baker IV contracture—and exclusions where removal is considered not medically necessary (for example, removal for 'breast implant illness'/'silicone implant illness' or removal of textured implants solely due to concern about BIA-ALCL).

Policy Summary

PayerEmblemHealth

PolicyBreast Implants and Reconstruction

Policy CodePolicy MG.MM.SU.14jC

Change TypeCoverage and exclusion updatescoding/billing redirects

Effective Date

Next Review Date

Key ActionSubmit clinical evidence and imaging (including noncontrast MRI when applicable) to support medical necessity for implant removal, capsulectomy, reinsertion, or replacement.

SourceLink

On This Page

Documentation requirementMedical record should specify how rupture is documented (e.g., obvious distortion/deformity on exam or history of change).

Rupture confirmationObjective imaging evidence is required to document implant rupture when indicated for coverage decisions.

HCPCS S2066–S2068 are redirected to the Reimbursement Policy.

Documentation Required

Documentation required for authorization: indication, symptoms, imaging

Supply the original indication for implantation, current symptoms, and an imaging study (mammography, MRI, or ultrasonography) when submitting an authorization request—imaging is required to demonstrate rupture when applicable.

Imaging modalities listed: mammography, MRI, ultrasonography.

Documentation Required

Document how rupture is established; cite noncontrast MRI when applicable

Medical records must specify how implant rupture is documented (for example, obvious distortion/deformity on exam or a history of change); noncontrast MRI is cited as the best noninvasive test for silicone gel implant rupture.

Document physical exam findings or history of change that support rupture.

Denial Risk

Missing clinical documentation may lead to denial

Failure to submit clinical evidence that the member meets the policy criteria will prevent proper preauthorization or post‑payment review and may result in denial.

Note

No action required

Not applicable — no provider action specified in this inventory item.

Note

Reserved provider action note

Reserved — additional provider action notes referenced in the policy revision history; no specific clinical action detailed in this inventory item.

Denial Risk

Not medically necessary: textured implants and implant‑illness indications

Removal of textured implants due to fear of BIA‑ALCL and removal for “breast implant illness” or “silicone implant illness” are explicitly listed as not medically necessary and therefore are subject to denial.

Denial Risk

Limitation: ruptured saline implant removal not medically necessary

Policy states that removal of ruptured saline‑filled implants is considered not medically necessary; document clearly if a saline rupture is alleged, as this limitation affects coverage.

Capsular contracture is tightening of the capsule (scar tissue) surrounding an implant, resulting in firmness or hardening of the breast.

Grading systemThe Baker Classification grades capsular contracture from Class I to IV based on firmness, visibility, and symptoms.

Clinical descriptorsClass I: soft and normal feel; Class II: less soft, implant palpable but not visible; Class III: firm with visible implant/distortion; Class IV: hard, painful, cold, tender, and distorted.

Rupture (silicone implant) — definition and consequences

Definition of ruptureRupture is physical disruption of the solid silicone elastomer shell of a silicone gel implant resulting in macroscopic migration of silicone out of the implant (distinct from gel bleed).

Clinical consequenceRupture allows migration of silicone beyond the implant shell, which may be evident on imaging or physical exam.

DocumentationMedical record should specify how the implant rupture is documented (e.g., obvious distortion or deformity on exam or history of change).