7.01.533_2026 07 02
Defines medical necessity criteria for reconstructive breast surgery, explantation (removal) of breast implants, reduction mammaplasty site-of-service rules, documentation requirements, coding references, and background including BIA-ALCL and regulatory guidance. Applies site-of-service medical necessity determinations for elective surgical procedures (excludes IHS facilities).
Poland syndrome added to list of breast diseases for which reconstructive breast surgery may be considered medically necessary when criteria are met.
CPT 15769 and HCPCS C1789 were added to the policy code list.
Removed hospital medical center from the medically necessary sites of service for elective surgical procedures; only Ambulatory Surgical Center listed.
Clarified that Baker class III contractures and rupture of a saline implant in individuals with implants for cosmetic purposes are considered not medically necessary.
BIA-ALCL added as an indication for removal of implants placed for cosmetic purposes.
Policy scheduled for deletion and replacement with InterQual on 07/02/20 was reversed; policy reinstated.
HCPCS codes S2067 and S2068 removed from the policy.
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.