CurrentKaiser PermanentePolicy N/A

Breast implant removal and re-implantation

Defines medical necessity criteria and documentation/authorization guidance for removal and re‑implantation of breast implants, primarily for reconstructive indications and related complications; applies to Kaiser Foundation Health Plan of Washington members.

Policy Summary

PayerKaiser Permanente

PolicyBreast implant removal and re-implantation

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateFeb 4, 2025

Key ActionObtain pre-authorization and submit last 6 months of radiology and clinical notes to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Allcriteria required for medical necessity

Baker II–IVcapsular contracture severity listed as indication

19328,19330example procedure codes listed

6 monthsrecommended supporting records

Coverage Criteria

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Top-level: Breast implant removal and re-implantation may be medically necessary when all listed conditions are present

Criteria: 1) Implants were part of a reconstructive procedure meeting criteria for breast reconstructive surgery; AND 2) One or more of the following clinical indications are present:

Clinical indications (one or more required)

Infection related to the implant
Extrusion: Implant extrusion
Capsular contracture: Baker Classification Class II to IV contracture
Ruptured implant
Interference with cancer care: Interference with diagnosis and/or treatment of breast cancer

Additional: Removal and subsequent re-implantation may be covered when implants were placed for a diagnosis of breast cancer or other malignancy involving the breast if criteria for Breast Reconstruction or Breast Prostheses following Mastectomy/Lumpectomy are met

Elective removal of existing breast implants for the purpose of preventing breast cancer is not recommended and does not meet Kaiser Permanente Medical Technology Assessment criteria. Historical MTAC review concluded there is no evidence linking silicone breast implants to cancer and therefore does not support implant removal solely for cancer prevention.

Removal of implants solely for cancer prevention or in the absence of the reconstructive indications and complications listed in this policy is considered not medically necessary. The MTAC review found no epidemiological evidence to justify elective explantation for cancer risk reduction and therefore does not support coverage for such procedures.

Provider Actions & Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for listed CPT codes. Verify authorization requirements for the specific code and member plan using the Pre-authorization Code Check prior to scheduling or billing.

Use Pre-authorization Code Check to confirm plan-specific requirements and any updates to covered or deleted codes.

Note

Provider Actions (General)

Provider must submit clinical justification demonstrating that the procedure meets all medical necessity criteria (see coverage criteria). Preferred specialists: Plastic Surgery credentials are preferred for breast implant removal and re‑implantation.

Ensure documentation explicitly addresses reconstructive indication or one of the listed qualifying clinical symptoms (e.g., infection, extrusion, rupture, Baker class II–IV contracture, interference with cancer diagnosis/treatment).

Documentation Required

Required Supporting Documentation

If requesting these services, include the following supporting documentation to substantiate medical necessity.

Last 6 months of relevant radiology reports (if applicable).
Last 6 months of clinical notes from the requesting provider and/or specialist.
Operative reports and pathology reports, when applicable.
Documentation of implant indication (e.g., reconstruction after mastectomy) and any prior procedures related to the breast implants.

Denial Risk

Denial Risk / Not Medically Necessary Scenarios

Requests that do not meet all listed clinical criteria will be denied as not medically necessary (for example, requests for cosmetic-only implant revision or re-implantation without qualifying indications).

Cosmetic-only implant changes or replacements without medical indications are not covered.
Missing required supporting documentation (radiology/clinical notes) increases denial risk.

Background

Breast implant removal is considered medically necessary only in limited reconstructive circumstances. Coverage is reserved for cases where implants were placed as part of a qualifying reconstructive procedure and when one or more of the following complications or clinical issues are present: infection related to the implant, implant extrusion, ruptured implant, clinically significant capsular contracture (Baker Class II–IV), or interference with diagnosis and/or treatment of breast cancer. Historical MTAC review further clarifies that implants placed for cosmetic augmentation do not impede cancer detection in the reconstructive setting, and elective removal for cancer prevention is not supported by the evidence.