CurrentPremera BluecrossPolicy 7.01.153

Adipose-Derived Stem Cells in Autologous Fat Grafting to the Breast

This policy governs coverage for the use of adipose-derived stem cells (ADSCs) as an adjunct to autologous fat grafting to the breast, addressing when the procedure is considered investigational and which codes are associated. It applies to providers performing breast reconstruction or related procedures using ADSC-enriched fat grafts.

Policy Summary

PayerPremera Bluecross

PolicyAdipose-Derived Stem Cells in Autologous Fat Grafting to the Breast

Policy CodePolicy 7.01.153

Change TypeAnnual review — no material changes

Effective DateApr 1, 2026

Next Review DateApr 1, 2026

Key ActionDo not submit claims for ADSC-enriched autologous fat grafting to the breast as it is considered investigational and may be denied.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

InvestigationalPolicy stance on ADSC use

InsufficientEvidence conclusion

CPT 11950-11954,15771-15774,19380,19499Procedure codes listed

Nov 20, 2025Last literature search

Coverage Determinations

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Investigational / Not Covered

Coverage determination

Investigational stance: The use of adipose-derived stem cells in autologous fat grafting to the breast is considered investigational.

Autologous fat grafting to the breast without the use of adipose-derived stem cells is not subject to this investigational determination (see related medical policies).

Not Medically Necessary / Investigational

Not covered when using ADSC in autologous fat grafting to the breast

Investigational stance: Use of adipose-derived stem cells (ADSC) in autologous fat grafting to the breast is considered investigational.

Policy statement has remained unchanged through multiple annual reviews.

Autologous fat grafting to the breast without the use of adipose-derived stem cells (ADSCs) is explicitly excluded from the investigational determination in this policy: such procedures are not subject to medical review for breast reconstruction following mastectomy for treatment of breast disease. Providers performing standard autologous fat grafting (no ADSC enrichment) should follow related reconstructive breast policies and routine coverage rules.

This medical policy addressing adipose-derived stem cells in autologous fat grafting to the breast does not apply to Medicare Advantage. Providers and members with Medicare Advantage benefits must consult the member benefit booklet or contact a customer service representative to determine applicable coverage rules and limits.

The evidence base for ADSC-enriched autologous fat grafting to the breast is limited and heterogeneous, consisting mainly of small, often single-arm observational studies with variable patient selection, stem cell isolation methods, number of procedures, and outcomes measured. Reported outcomes have generally been patient or investigator satisfaction and short-term functional or cosmetic results. One small prospective study suggested improved graft retention at 6 and 12 months with ADSC enrichment, but sample sizes and follow-up durations are insufficient to confirm durable benefit. Additionally, uncertainty remains about potential oncologic effects of ADSCs. Overall, the evidence is insufficient to demonstrate improved net health outcome, and limitations in quantity and quality of data support an investigational stance.

Consistent with the policy statement and its history of annual review, the use of adipose-derived stem cells (ADSC) as an adjunct to autologous fat grafting to the breast is considered investigational. Claims or requests for ADSC-enriched fat grafting to the breast may be denied as not medically necessary under this policy.

Procedure and Billing Codes

Procedure CPT codes listedCPT

11950	Subcutaneous injection of filling material (e.g., collagen); 1 cc or less.
11951	Subcutaneous injection of filling material (e.g., collagen); 1.1 to 5.0 cc.
11952	Subcutaneous injection of filling material (e.g., collagen); 5.1 to 10.0 cc.
11954	Subcutaneous injection of filling material (e.g., collagen); over 10.0 cc.
15771	Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate.
15772	Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (list separately in addition to code for primary procedure).
15773	Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate.
15774	Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure).
19380	Revision of reconstructed breast (e.g., significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction).
19499	Unlisted procedure, breast

Coding history mentionsmixed

11950	Described in history as added
11951	Described in history as added
11952	Described in history as added
11954	Described in history as added
15769	Added then later removed per history
15771	Added
15772	Added
15773	Added and subsequently removed/added in coding updates
15774	Added and subsequently removed/added in coding updates
20926	Replaced by new codes effective 1/1/20; removed from policy

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Provider Responsibilities and Billing Guidance

Denial Risk

Code listing and investigational coverage

Code listing below identifies CPT codes related to autologous fat grafting procedures. The use of adipose-derived stem cells (ADSC) in autologous fat grafting to the breast is considered investigational; submission or billing of the related procedure codes for ADSC use may result in claim denials. Verify member benefits and prior authorization requirements before performing procedures.

Affected CPT codes: 11950, 11951, 11952, 11954, 15771, 15772, 15773, 15774, 19380, 19499
Investigational coverage: Use of adipose-derived stem cells (ADSC) in autologous fat grafting to the breast is investigational and not covered
Benefit verification: Consult member benefit booklet or contact customer service to confirm coverage and prior authorization requirements

Documentation Required

Coding & documentation note

Report the appropriate CPT code(s) that describe the autologous fat grafting procedure performed. If adjunctive products or injections (for example, any injected stem cell preparations or other biologic/adjunct agents) are used, document their use clearly in the operative report and medical record. Documentation should include the product/agent name, quantity, route, and clinical rationale. Claims for ADSC use may be denied due to investigational status.

Document procedure details: operative notes must describe technique, volumes injected, and anatomic sites
Adjunct injections: if any biologic or stem cell product is used, document product name, amount, route, and indication
Coding tip: select the CPT code(s) that most accurately reflect the service (see Code listing callout)

Prior Authorization

Prior authorization / Benefit verification

Before scheduling procedures, verify member benefits and any prior authorization requirements. This medical policy does not guarantee coverage; coverage is determined by the member's benefit plan. Contact customer service or review the member benefit booklet for plan-specific limits and prior authorization procedures.

Verify benefits and prior authorization with the payer
Confirm whether exclusions or plan limits apply to autologous fat grafting or use of adjunctive products such as ADSC

Clinical Background

Autologous fat grafting transfers a patient’s own adipose tissue from one body site to the breast and is used as an adjunct to breast reconstruction after mastectomy or lumpectomy for contouring, volume restoration, management of irradiated tissue, and relief of post-mastectomy pain. Adipose-derived stem cells (ADSCs) are multipotent cells concentrated from adipose tissue that have been proposed to improve fat graft survival by differentiating into adipocytes and endothelial cells and by releasing angiogenic factors; methods to isolate or concentrate ADSCs include centrifugation and enzymatic digestion (often described as cell-assisted lipotransfer). While these biological mechanisms provide a theoretical rationale for ADSC enrichment, clinical evidence about effectiveness and long-term safety—particularly oncologic risk—remains uncertain.

Key Terms

Definition of ADSCs — biology, mechanisms, isolation methods

Biology / proposed mechanismsADSCs can differentiate into adipocytes and endothelial cells and release angiogenic growth factors; these actions may improve graft survival by providing new adipose tissue, increasing blood supply, accelerating wound healing, and protecting grafts from ischemia–reperfusion injury.

Isolation methodsMethods include centrifugation and enzymatic techniques (collagenase digestion followed by centrifugal separation) and point-of-care systems (eg, Celution) to concentrate ADSCs from lipoaspirate; cell-assisted lipotransfer mixes an ADSC-rich fraction with washed lipoaspirate.

Cell yield and sourceAdipose tissue is an abundant source: ~5,000 stem cells per gram (100–500× the number in equivalent bone marrow), making adipose a readily accessible source for ADSC-based approaches.

Laboratory handling / expansionIsolated ADSCs can be expanded in monolayer culture on standard tissue culture plastic with basal medium (eg, 10% fetal bovine serum); newer serum-free culture conditions are under development and a standard expansion method is not established.

Clinical technique exampleCell-assisted lipotransfer: part of the lipoaspirate is centrifuged to concentrate ADSCs, while another fraction is enzymatically digested and combined to create ADSC-rich fat for transfer.

ADSC — short definition / alias

Short definition / aliasAdipose-derived stem cells (ADSCs) — multipotent stem cells concentrated from adipose tissue, proposed to enhance fat graft survival.

Alternate short formADSC (singular abbreviation commonly used in the literature).

Clinical context noteUsed as an adjunct in autologous fat grafting to potentially improve graft retention, though considered investigational in this policy.