ModifiedPremera BluecrossPolicy N/A

Reconstructive breast surgery and explantation of breast implants

Defines medical necessity criteria, site-of-service guidance, documentation requirements, and coding for reconstructive breast surgery and implant explantation; applies to providers and Premera Bluecross plan administration.

Policy Summary

PayerPremera Bluecross

PolicyReconstructive breast surgery and explantation of breast implants

Policy CodePolicy N/A

Change TypeMaterial clinical and coding updates

Effective DateJul 2, 202620d

Next Review DateN/A

Key ActionObtain prior authorization for elective reconstructive breast procedures as required by plan and submit documentation supporting the original indication and qualifying conditions for explantation.

SourceLink

POLICY UPDATE CHANGES

Poland syndrome was added to the list of breast diseases for which reconstructive breast surgery may be considered medically necessary when criteria are met.

CPT code 15769 and HCPCS code C1789 were added.

Clarified that Baker class III contractures and rupture of a saline implant in individuals with implants for cosmetic purposes are considered not medically necessary.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) was added as an indication for removal of implants placed for cosmetic purposes.

07/02/2026Poland addition effective

1380Confirmed BIA-ALCL cases

64Known BIA-ALCL deaths

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.

Coverage Criteria for Reconstructive Breast Surgery and Explantation

Reconstructive surgery indications

Reconstructive breast surgery may be considered medically necessary in ANY of the following circumstances:

Reconstructive indications: A prior mastectomy or partial mastectomy performed to treat breast disease (including breast cancer or severe fibrocystic breast disease unresponsive to medical therapy); Poland syndrome when determined by clinical exam or imaging with ALL of the following present: congenital absence or hypoplasia of the pectoralis major and/or minor muscles and breast hypoplasia; to treat breast injury or trauma; prophylactic mastectomy to reduce risk of breast cancer occurrence; or reconstruction to restore symmetry between the unaffected breast and the affected breast.

Document with clinical exam or imaging as applicable

Explantation criteria

Explantation of silicone gel or saline-filled breast implant may be considered medically necessary when the original implant was placed for medically necessary reconstructive purposes and ONE or more of the following are present:

Explantation main rule: Original implant must have been placed for medically necessary reconstructive reasons (not cosmetic).

AND at least one qualifying condition below must be present; submit documentation that the original implant was placed for a medically necessary reason

Qualifying conditions for explantation: Baker Class III or IV contracture; documented implant rupture of implants placed after a medically necessary mastectomy or partial mastectomy (rupture requires imaging confirmation such as mammography, MRI, or ultrasonography); extrusion; infection; surgical treatment of breast cancer or other malignancy involving the breast; breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).

Pain alone is inadequate indication unless related to Baker classification or rupture; lack of imaging confirmation with persistent local symptoms handled case-by-case

Site-of-service criteria

Certain elective surgical procedures (including reduction mammaplasty and other listed procedures) will be covered in the most appropriate, safe, and cost-effective site; Ambulatory Surgical Centers (ASCs) are preferred but hospital outpatient departments may be considered when ASC is not accessible or patient/clinical factors require it.

Medically necessary site-of-service: Ambulatory Surgical Center; Off campus-outpatient hospital/medical center; On campus-outpatient hospital/medical center when no accessible ASC or when patient meets specific criteria (e.g., age 18 or younger, additional service requiring hospital outpatient department, lack of ASC equipment or physician privileges).

Specific clinical risks may mandate HOPD vs ASC (see anesthesia, cardiac, liver, pulmonary, renal, obesity, pregnancy, bleeding disorders)

Not medically necessary site-of-service: Inpatient hospital/medical center is considered NOT medically necessary for these elective surgical procedures unless site-of-service criteria are met.

Elective procedures performed inpatient without meeting criteria are not medically necessary

Coverage summary

Coverage conclusions summarized from evidence:

Reconstructive surgery: Breast reconstruction after surgery or injury (e.g., mastectomy) improves psychosocial outcomes and is supported by case series; benefits are mandated by federal/state law.

Supported by evidence summary; federal/state mandates referenced

Explantation for documented complication: Explantation for documented implant rupture, infection, extrusion, Baker contracture, or in the setting of surgical treatment of breast cancer is considered medically necessary; medical necessity depends on implant type and original indication for implantation.

Evidence from case series supports explantation for these indications

Preventive explantation to reduce ALCL risk: Prophylactic explantation of asymptomatic implants to reduce BIA‑ALCL risk lacks evidence that removal reduces risk and carries surgical risks; evidence is insufficient to support routine preventive explantation.

Systematic reviews and epidemiologic data do not demonstrate benefit; prophylactic removal not supported by current evidence

Covered indications and exclusions (excerpted)

Policy-level covered indications and clarifications referenced in history and citations

BIA-ALCL indication: Removal of implants is indicated for individuals with breast implant-associated anaplastic large cell lymphoma (BIA-ALCL).

Added to indications for explantation per 06/10/20 history entry; complete surgical excision recommended in cited literature

Poland syndrome reconstructive coverage: Reconstructive breast surgery may be considered medically necessary for Poland syndrome when policy criteria are met.

Poland syndrome explicitly added to list of breast diseases in 04/01/26 review; effective July 2, 2026.

Not medically necessary examples: Baker class III contractures and rupture of a saline implant in individuals with implants placed for cosmetic purposes are considered not medically necessary.

Clarified in 09/01/24 history entry

Explantation of implants placed for cosmetic purposes is generally considered not medically necessary unless there is interval development of breast cancer, breast implant‑associated anaplastic large cell lymphoma (BIA‑ALCL), or other breast disease requiring mastectomy or partial mastectomy. Specifically, removal for cosmetic implants is not medically necessary for Baker class III contractures when the original implant was placed for cosmetic reasons, for pain not related to contracture or rupture, for patient anxiety, for rupture of a saline implant placed for cosmetic purposes, or for systemic symptoms attributed to connective tissue/autoimmune disease. (Explantation for these circumstances may be treated as a complication of a non‑covered service and contractually excluded.)

Current evidence does not demonstrate that routine removal of asymptomatic breast implants reduces the risk of BIA‑ALCL. Systematic reviews and epidemiologic data have not provided evidence that prophylactic explantation of asymptomatic implants improves long‑term outcomes, and explantation carries known surgical risks. For these reasons, routine prophylactic removal of implants in asymptomatic individuals is not supported by evidence and is not recommended as a standard practice.

Services are considered not medically necessary when the policy's medical necessity criteria are not met. For clarification: when implants were placed for cosmetic purposes, explantation for Baker class III contractures or for rupture of a saline implant is considered not medically necessary (see policy history and exclusions). Removal in these situations is generally covered only if a subsequent qualifying breast disease (e.g., cancer or BIA‑ALCL) develops that requires mastectomy or partial mastectomy.

Elective reconstructive and related breast surgical procedures are expected to be performed in the most appropriate, safe, and cost‑effective site of service. An inpatient hospital/medical center admission for an otherwise elective procedure is considered not medically necessary unless the policy's site‑of‑service criteria are met (for example: no accessible ASC within 30 miles with necessary equipment/privileges, age ≤18 years, procedures combined with an additional service requiring a hospital outpatient department, or patient meets specific medical risk criteria such as ASA III or higher, significant cardiac, pulmonary, liver, renal, obesity [BMI ≥50], bleeding disorder, prolonged expected surgery [> 3 hours], or anticipated need for transfusion).

Explantation of implants that were placed for cosmetic reasons is considered not medically necessary for the following scenarios unless other qualifying conditions are present: pain that is not related to Baker contracture or implant rupture; removal driven primarily by patient anxiety; rupture of a saline implant when the implant was originally placed for cosmetic purposes; or systemic symptoms attributed to connective tissue/autoimmune disease. Coverage may be available only if a subsequent medical indication (e.g., cancer, BIA‑ALCL) arises that meets the policy's medical necessity criteria.

Preventive explantation of asymptomatic implants solely to reduce future risk of BIA‑ALCL is unsupported by current evidence. Systematic reviews and epidemiologic studies have not demonstrated that routine removal of asymptomatic implants reduces ALCL risk, and explantation carries operative risks; therefore, prophylactic removal for this purpose is not endorsed by the evidence and is considered unsupported.

For clarity, when implants were placed for cosmetic purposes, Baker class III contractures and rupture of a saline implant are specified in the policy as not medically necessary indications for explantation. Explantation in these cosmetic scenarios is covered only if a separate qualifying breast disease (for example, breast cancer or BIA‑ALCL) subsequently develops and meets the policy's medical necessity requirements.

Coding and Procedural Codes

Covered CPT and HCPCS CodesmixedCovered

11920	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq. cm or less
11921	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm
11922	Tattooing; each additional 20.0 sq cm
11970	Replacement of tissue expander with permanent implant
11971	Removal of tissue expander without insertion of implant
15769	Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)
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)
19316	Mastopexy
19318	Breast reduction

1–10 of 22

1/3

Recently added codesmixed

15769	CPT code added (Grafting of autologous soft tissue, other, harvested by direct excision)
C1789	HCPCS code added (Prosthesis, breast (implantable))

Historical coding changesCPT

11921	Previously added CPT code referenced in history
11922	Previously added CPT code referenced in history
11960	CPT code previously removed per history
11970	Previously added CPT code referenced in history
11971	Previously added CPT code referenced in history
19324	CPT code removed/terminated per history
19366	CPT code removed/terminated per history

BMI — morbid obesity threshold referenced for site-of-service considerations

Morbid obesity (BMI)BMI greater than or equal to 50

ASA anesthesia riskASA classification III or higher

Prolonged surgerySurgery duration greater than 3 hours

MELD Score — advanced liver disease threshold referenced

MELD Score thresholdMELD Score greater than 8

ContextListed as a liver-related clinical risk that may require higher-acuity site of service

Actions Required by Providers

Prior Authorization

Prior Authorization Required

Elective reconstructive procedures (including reduction mammaplasty and breast reconstruction/explantation) are subject to prior authorization and will be reviewed for medical necessity. Obtain prior authorization as required by the member’s plan before scheduling elective reconstructive surgery.

Prior authorization required per plan benefits and site-of-service rules.
Elective inpatient procedures are generally NOT medically necessary unless specific site-of-service criteria are met.

Documentation Required

Patient Decision Documentation & Device Labeling

Document the shared decision-making conversation and include the FDA-required patient decision checklist and device-specific labeling information (patient device card, boxed warning, device description/materials) in the medical record when applicable. Ensure the record reflects the individualized risk assessment and patient goals when discussing prophylactic or elective explantation.

Background and Context

Breast reconstruction is performed to restore breast appearance and form following prior surgery, accidental injury, or congenital abnormality; it is most commonly performed after mastectomy for breast cancer. Reconstruction includes implant‑based and autologous approaches and may include nipple/areola reconstruction and tattooing. The evidence supports that reconstruction improves psychosocial outcomes, including body image and social functioning, and local complications such as capsular contracture are common sequelae that may require explantation when occurring in the context of medically indicated implants.

Definitions and Clinical Classifications

Reconstructive surgery — definition

DefinitionSurgeries performed on abnormal structures caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to improve function or restore appearance.

Common indicationsIncludes reconstruction after mastectomy, trauma, or congenital deformity; may involve implant-based or autologous techniques

Examples of proceduresNipple/areola reconstruction, tattooing, tissue flaps (eg, TRAM), implant-based reconstruction

ASA Physical Status Classification — Standardized classification I–VI; ASA III or higher cited as important for site-of-service decisions

Classification scaleASA Physical Status Classification I–VI (standardized)

Operational threshold

Policy Revision History and Material Changes

2026-07-02policy_changeLatest

Poland syndrome was added to the list of breast diseases for which reconstructive breast surgery may be considered medically necessary when criteria are met; effective after 90-day notification.

2026-04-01annual_review

Annual review approved March 10, 2026; references updated and Poland syndrome added to reconstructive indications; effective July 2, 2026 and CPT 15769 and HCPCS C1789 added.

2025-09-01

Policy Summary

PayerPremera Bluecross

PolicyReconstructive breast surgery and explantation of breast implants

Policy CodePolicy N/A

Change TypeMaterial clinical and coding updates

Effective DateJul 2, 202620d

Next Review DateN/A

SourceLink

On This Page

ASA classification — anesthesia risk criterion referenced (ASA III+)

ASA classification thresholdASA III or higher

Definition sourceASA Physical Status Classification I–VI used to describe preoperative medical comorbidity and perioperative risk

Prolonged surgery — threshold > 3 hours referenced for site-of-service decisions

Prolonged surgery thresholdGreater than 3 hours

UseCited as a clinical factor increasing perioperative risk and influencing site-of-service decisions

COPD FEV1 — pulmonary function threshold referenced (< 50%)

COPD pulmonary function thresholdFEV1 less than 50%

ContextListed under pulmonary risk factors that may necessitate higher-acuity site of service

Include FDA patient decision checklist and device card when devices subject to FDA labeling orders are involved.
Document that risks, benefits, and alternatives were discussed and that the choice of reconstruction or explantation was shared between patient and surgeon.

Billing Rule

Coding Additions and PA Implications

Coding updates have occurred historically and may affect prior authorization and billing. Verify current CPT/HCPCS/ICD-10 codes with payer systems and include applicable codes on the authorization request. Coverage remains subject to plan benefit limits and site-of-service policies.

Provider should confirm current codes and any PA requirements prior to submission.
Prior authorization decisions are governed by member benefit limits and site-of-service determinations.

Denial Risk

Site-of-Service Denial Risk

Elective procedures performed inpatient are considered NOT medically necessary unless the individual meets specified site-of-service exceptions (e.g., no accessible ASC within 30 miles, age ≤18, concomitant procedures requiring hospital outpatient department, or significant medical risk factors such as ASA III+, morbid obesity, significant cardiopulmonary comorbidity).

ASC is preferred medically necessary site-of-service when appropriate.
Inpatient site of service for elective procedures is not medically necessary when site-of-service criteria are not met.

Denial Risk

Denial Risk When Criteria Unmet

Services will be denied (considered not medically necessary) when policy clinical criteria are not met. Examples include Baker class III contractures or saline implant rupture when the original implant was placed for cosmetic purposes, pain alone without contracture or rupture, and preventive explantation of asymptomatic implants without documentation of benefit.

Explantation of implants placed for cosmetic purposes is covered only if there is interval development of breast cancer, BIA-ALCL, or other breast disease requiring mastectomy/partial mastectomy.
Preventive explantation for asymptomatic implants to reduce ALCL risk lacks evidence of net benefit and may be denied.

Documentation Required

Required Clinical Documentation

Submit complete clinical documentation to support medical necessity for reconstruction or explantation. For reconstructive surgery include documentation of prior mastectomy/partial mastectomy (indication: cancer, severe fibrocystic disease, Poland syndrome, trauma, or prophylactic mastectomy) or documentation that reconstruction is to restore symmetry. For explantation, document the original indication for implantation (reconstructive vs cosmetic), implant type, and current clinical findings.

For Poland syndrome, include exam or imaging documenting pectoralis muscle absence/hypoplasia and breast hypoplasia.
For explantation, document that the implant was originally placed for a medically necessary reason when coverage is claimed.
Include implant type (saline vs silicone gel) and original operative reports when available.

Documentation Required

Imaging Required for Suspected Implant Rupture

Rupture of implants requires imaging confirmation. Acceptable modalities include mammography, MRI, or ultrasound. Lack of imaging confirmation with persistent local symptoms will be considered case-by-case; isolated pain without supporting findings is generally inadequate.

Order ultrasound or MRI without contrast for concern of silicone implant rupture; ultrasound often appropriate as initial imaging for suspected BIA-ALCL.
For saline implants, clinical evidence of rupture may be sufficient per imaging appropriateness guidance.

Documentation Required

Diagnostic Documentation for Suspected BIA-ALCL

Diagnostic evaluation for suspected BIA-ALCL must include aspiration of the peri-implant effusion with cytology and immunohistochemistry demonstrating CD30+ large anaplastic T‑cells and flow cytometry as indicated; follow NCCN and multidisciplinary guidance for staging and management. Report confirmed and suspected cases to registries such as the PROFILE registry.

Obtain CD30 immunohistochemistry and flow cytometry from aspirated fluid; histologic confirmation and oncologic staging per NCCN guidance.
Treatment typically requires total capsulectomy and implant removal; coordinate care with oncology as indicated.
Report cases to the PROFILE registry and document registry submission when applicable.

Note

Supporting Documentation and Registry Reporting

Include supporting references, registry reporting, and professional society guidance in the record to corroborate clinical decisions. Useful resources include ASPS BIA-ALCL materials, NCCN guidelines on reconstruction and BIA-ALCL, FDA device labeling/orders, and the PROFILE registry.

Document when professional society recommendations (ASPS, NCCN) or FDA labeling influenced the treatment plan.
When reporting BIA-ALCL cases, reference the PROFILE registry and retain submission confirmation in the chart.

Note

Shared Decision-Making Requirement

Engage in shared decision-making and individualized risk assessment prior to prophylactic explantation or selection of reconstruction. The decision should balance patient goals, potential risk reduction (particularly for textured implants), surgical risks, and lack of evidence for routine preventive explantation; document that this process occurred.

Discuss implant surface type (textured vs smooth) and implications for BIA-ALCL risk.
Document that the final decision regarding explantation or capsulectomy was made jointly by patient and surgeon after discussion of risks and benefits.

ASA III or higher cited as increased anesthesia risk for site-of-service decisions

ExamplesASA III: severe systemic disease (eg, morbid obesity BMI ≥40, COPD, poorly controlled DM/HTN); ASA IV–V indicate higher perioperative risk

Baker Classification — Capsular contracture grading I–IV; Baker III–IV listed as indications for explantation when clinically indicated

Baker gradesGrade I: soft; Grade II: less soft, palpable implant not visible; Grade III: firm, implant visible/distorted; Grade IV: hard, painful, distorted

Clinical implicationBaker Class III–IV are listed as indications for explantation when implants were placed for medically necessary reconstruction

Reconstructive breast surgery definition — Distinction from cosmetic procedures based on presence of medical condition such as cancer

DefinitionReconstructive breast surgery: procedure to restore normal breast appearance after surgery, accidental injury, or trauma; distinguished from cosmetic procedures by presence of a medical condition such as breast cancer

Common indicationPrior mastectomy is the most common indication; reconstruction may include implants or autologous tissue

BIA‑ALCL definition — Rare T‑cell lymphoma around textured implants; diagnostic criteria and typical presentation summarized

DefinitionBreast Implant‑Associated Anaplastic Large Cell Lymphoma (BIA‑ALCL) is a rare T‑cell lymphoma occurring around textured implants, usually presenting as seroma/effusion

Diagnostic criteriaDiagnosis requires CD30+ large anaplastic T‑cell lymphocytes by immunohistochemistry and flow cytometry from aspirated fluid with histologic confirmation

Typical presentationPresenting symptom commonly a seroma or effusion with breast swelling around the implant capsule; onset ranges 2–28 years post-implantation

BIA-ALCL — referenced as an indication for explantation requiring surgical excision and diagnostic confirmation

Indication for surgeryBIA‑ALCL is an indication for explantation and requires complete surgical excision (total capsulectomy and implant removal)

Diagnostic confirmationSurgical excision and histologic confirmation following diagnostic aspiration and CD30+ immunophenotyping are required

Poland syndrome — congenital chest wall/breast developmental disorder added to list of breast diseases for which reconstructive surgery may be considered medically necessary

DefinitionPoland syndrome: congenital disorder with absence or hypoplasia of pectoralis major/minor, chest wall and breast hypoplasia, nipple abnormalities, and possible hand/upper extremity anomalies

Surgical relevanceSurgical correction may include breast augmentation, musculocutaneous flap reconstruction, prosthetic augmentation, or chest wall repair

Policy changePoland syndrome was added to the list of breast diseases for which reconstructive surgery may be considered medically necessary when criteria are met (effective July 2, 2026)

Annual review approved August 12, 2025 with literature update through April 11, 2025; policy statements unchanged.

2025-07-03related_policy_update

Minor update to Related Policy section: Bioengineered Skin and Soft Tissue Substitutes policy renumbered (7.01.113 deleted and replaced with 7.01.582) and Related Policy 11.01.525 added.

2024-11-01minor_update

Minor update made to the BCBSA Reference policy section.

2024-09-01annual_review

Annual review approved August 12, 2024; clarified that Baker class III contractures and rupture of a saline implant in individuals with implants placed for cosmetic purposes are considered not medically necessary.

2023-09-01annual_review

Annual review approved August 7, 2023 with literature review through May 1, 2023; wording standardized from 'patient' to 'individual' and policy statements otherwise unchanged.

2023-04-01coding_update

Coding update: removed HCPCS codes S2067 and S2068.

2023-03-01coding_update

Coding update: CPT code 19380 description updated.

2020-06-10interim_review

Policy reinstated (no longer deleted) and BIA-ALCL was added as an indication for removal of implants placed for cosmetic purposes; CPT codes 15771 and 15772 were added.

2020-04-01operational_change

Policy deletion approved March 10, 2020 to be effective July 2, 2020 and replaced with InterQual criteria; subsequently reversed prior to that effective date.

2019-07-01annual_review

Annual review approved June 11, 2019; references added and medically necessary indication of BIA-ALCL added to policy.

2018-09-07coding_update

Coding update added multiple CPT codes including 11922, 11960, 11970, 11971, 19303, 19304, 19324, and 19325.

2018-06-19site_of_service_update

Site of Service information added to the policy.

2007-07-10policy_revision

Policy updated with literature review and policy statement revised to indicate medical necessity for reconstructive surgery after mastectomy or trauma and explantation when original surgery met medically necessary criteria.

1997-02-01policy_creation

New policy created and added to the Surgery section (initial policy history entry in Feb 1997).

Billing Rule

Use newly added CPT 15769 and HCPCS C1789 where applicable

When submitting prior authorization or claims involving the newly added codes, use CPT 15769 and HCPCS C1789 as applicable effective per the policy history entry.

Policy history (04/01/26) records addition of CPT 15769 and HCPCS C1789—include these codes when relevant.
Verify member benefit coverage and PA requirements for these codes prior to scheduling.