Breast Implant Removal
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Criteria and coverage rules for removal and reinsertion of breast implants, including indications, limitations, coding, and prior authorization documentation requirements for Moda Health members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Breast Implant Removal
Silicone implant removal - primary indications
Silicone breast implant removal is considered medically necessary when ANY of the following are met:
Removal following medically necessary reconstruction
For implants placed after medically necessary mastectomy or lumpectomy, removal is considered medically necessary when ANY of the following are met:
Saline rupture after cosmetic augmentation
Saline-filled ruptured implants following cosmetic augmentation:
See Not Medically Necessary section for cosmetic indications
Removal of breast implants is excluded when performed solely for psychological or psychosocial complaints, solely to improve appearance, or solely for the possible influence on autoimmune or connective tissue disorders. Moda Health identifies these indications as not medically necessary and they are subject to denial. The policy notes that current literature and professional organizations do not support a causal link between breast implants and autoimmune/connective tissue disease.
Removal of implants for nonspecific somatic complaints is explicitly identified as not a covered benefit. For cosmetic augmentation, Moda Health considers removal of ruptured saline-filled implants not medically necessary. Providers should document clinical findings that meet medical indications in the policy; cosmetic-only complaints and nonspecific symptoms without objective evidence do not meet coverage criteria and risk denial.
Coding and Diagnosis Codes
| 19328 | Removal of intact mammary implant |
| 19330 | Removal of mammary implant material |
| 19371 | Periprosthetic capsulectomy, breast |
| L8015 | Breast prosthesis |
| L8020 | Breast prosthesis |
| L8030 | Breast prosthesis |
| L8031 | Breast prosthesis |
| L8032 | Breast prosthesis |
| L8035 | Breast prosthesis |
| L8039 | Breast prosthesis |
| 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 |
Prior Authorization & Documentation Requirements
Prior authorization required; affected removal and prosthesis codes
Prior authorization is required and authorization requests must use the listed CPT/HCPCS codes for implant removal and capsulectomy (including 19328, 19330, 19371 and L8015, L8020, L8030, L8031, L8032, L8035, L8039, L8600). Chart notes and imaging must be submitted when applicable to support medical necessity.
Provider impact: cosmetic saline rupture and nonspecific complaints
Note that removal of ruptured saline-filled breast implants is considered NOT medically necessary for individuals whose implants were placed for cosmetic augmentation; removal for nonspecific somatic complaints is also not a covered benefit.
- Ruptured saline implants placed for cosmetic augmentation: removal NOT medically necessary
- Removal for nonspecific somatic complaints is not covered
Documentation required with prior authorization
Submit the treating physician’s chart notes with the prior authorization request; if implant leakage is the reason for removal, include imaging confirmation or reports (MRI, mammogram, or ultrasound).
- Chart notes from the treating physician
- Imaging reports (MRI, mammogram, or ultrasound) when leakage is the reason for removal
Denial risk: cosmetic or psychological-only indications
Removals performed solely to treat psychological or psychosocial complaints, solely to improve appearance, or solely for potential influence on autoimmune/connective tissue disorders are considered not medically necessary and are at risk of denial.
- Solely for psychological/psychosocial complaints
- Solely to improve appearance
- Solely for possible influence on autoimmune or connective tissue disorders
Key Definitions
Background
Breast implants are used for reconstruction after mastectomy or for cosmetic augmentation. Removal may be necessary for complications related to the implant such as capsular leakage, infection, capsular contracture (graded by the Baker Classification I–IV), pain, extrusion/exposure, or tissue necrosis. The policy also recognizes removal when implants interfere with diagnostic evaluation of suspected breast cancer, for confirmed breast cancer, and for breast implant–associated anaplastic large cell lymphoma.
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