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    v1.0.31
    OpenPayerPolicy UpdatesPlastic/Reconstructive SurgeryRegence Breast Reconstruction Coverage | OpenPayer
    Ask Trek AI about this page
    CurrentRegencePolicy N/A

    Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants

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    This policy governs coverage criteria, documentation, and coding for breast reconstruction, symmetry procedures, mastopexy, breast implant explantation or replacement, and related prostheses, subject to applicable contract terms and exclusions.

    Policy Summary
    PayerRegence
    PolicyReconstructive Breast Surgery/Mastopexy, and Management of Breast Implants
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOctober 1, 2026
    Last ReviewAug 1, 2026
    Next Review DateAugust 1, 2027
    Key ActionSubmit history and physical examination and chart notes for review.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2026-10-01Effective date
    4Medically necessary coverage circumstances summarized
    2Implant-associated malignancies identified

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    31Procedure and supply codes listed
    3Cosmetic circumstances or procedures

    Medical Necessity and Coverage Criteria

    Reconstruction of the Diseased or Injured Breast

    Reconstructive breast surgery may be considered medically necessary when ALL of the following are met:

    ALL of the following

    • The breast is diseased or injured following prophylactic or therapeutic mastectomy, or following accidental injury or trauma resulting in significant malformation.
    • The treating physician recommends reconstructive breast surgery.

    Reconstruction of the Unaffected Breast for Symmetry

    Reconstructive breast surgery of an unaffected breast may be considered medically necessary when ALL of the following are met:

    ALL of the following

    • The surgery is intended to achieve symmetry with the contralateral breast.
    • Reconstruction of the contralateral diseased or injured breast was medically necessary under the policy criteria.
    • The treating physician recommends the surgery.

    Management of Implants Placed During Medically Necessary Reconstruction

    Breast implant explantation and/or replacement may be considered medically necessary when ALL of the following are met:

    ALL of the following

    • The implant or implants were placed during reconstructive breast surgery.
    • The reconstructive breast surgery was medically necessary under the policy criteria.

    Explantation for Implant-Associated Malignancy

    Breast implant explantation may be considered medically necessary when ANY of the following pathologically confirmed diagnoses is present:

    ANY of the following

    • Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is pathologically confirmed.
    • Breast implant-associated squamous cell carcinoma (BIA-SCC) is pathologically confirmed.

    Cosmetic or Not Medically Necessary Breast Surgery

    The following procedures are considered cosmetic and not medically necessary when the applicable medical-necessity criteria are not met:

    ANY of the following

    • Breast revision surgery, including breast implant explantation and/or replacement, following a cosmetic primary breast procedure, when medical-necessity criteria are not met.
    • Mastopexy, when medical-necessity criteria are not met.

    This policy does not address procedures related to gender-affirming interventions for gender dysphoria. See Cross References for the correct policy to be applied.

    Contractual limitations and exclusions may apply to both reconstructive and cosmetic procedures, to illnesses and conditions initially occurring prior to coverage, and to complications of non-covered procedures not specified in this policy.

    Breast revision surgery, including breast implant explantation and/or replacement, following a cosmetic primary breast procedure is considered cosmetic when medical-necessity criteria are not met.

    Mastopexy is considered cosmetic when medical-necessity criteria are not met.

    Procedure and Supply Coding

    Listed breast reconstruction, implant, flap, tattooing, and prosthesis codesmixed
    11920Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq. cm or less
    11921Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq. cm
    11970Replacement of tissue expander with permanent implant
    11971Removal of tissue expander(s) without insertion of implant
    15769Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)
    15771Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate
    15772Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof
    19316Mastopexy
    19318Breast reduction
    19325Breast augmentation with implant
    1–10 of 32
    1/4
    Not reported for breast fat graftingCPTNot Covered
    11950Subcutaneous injection of filling material (eg, collagen)
    11951Subcutaneous injection of filling material (eg, collagen)
    11952Subcutaneous injection of filling material (eg, collagen)
    11954Subcutaneous injection of filling material (eg, collagen)
    19366Breast flap graft, other technique
    19380Revision of reconstructed breast
    19499Unlisted procedure, breast

    Documentation and Request Requirements

    Documentation Required

    History and Physical Documentation Required

    Submit the patient’s history and physical examination and relevant chart notes for review. Missing documentation may affect the review and coverage decision.

    Documentation Required

    Pathology Required for Implant-Associated Malignancy

    For implant explantation requests due to breast implant-associated malignancy, submit pathologic confirmation of BIA-ALCL or BIASCC.

    • Confirmation may be from pre-operative percutaneous needle aspiration of a seroma.
    • Confirmation may be from a needle biopsy of a mass, if present.
    Denial Risk

    Clinical Context

    Reconstructive breast surgery restores the normal appearance of a breast after surgery, accidental injury, or trauma. Cosmetic breast surgery alters or enhances the appearance of a breast that has not been significantly altered by surgery, accidental injury, or trauma. Reconstructive procedures may include implants, tissue expanders, nipple or areola reconstruction, tattooing, autologous tissue flaps, fat grafting, or procedures on the opposite breast to achieve symmetry.

    Key Definitions

    Mastectomy
    ScopeComplete mastectomy
    ScopePartial mastectomy
    Included procedureLumpectomy
    Reconstructive breast surgery
    PurposeSurgical procedures intended to restore the normal appearance of the breast
    After surgeryMay restore the breast after surgery
    After injury or traumaMay restore the breast after accidental injury or trauma
    Policy Summary
    PayerRegence
    PolicyReconstructive Breast Surgery/Mastopexy, and Management of Breast Implants
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOctober 1, 2026
    Last ReviewAug 1, 2026
    Next Review DateAugust 1, 2027
    Key ActionSubmit history and physical examination and chart notes for review.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaProcedure and Supply CodingDocumentation and Request RequirementsClinical ContextKey Definitions

    Revision After Cosmetic Primary Surgery

    Breast revision surgery, including breast implant explantation and/or replacement, following a cosmetic primary breast procedure is considered cosmetic when medical-necessity criteria are not met.

    Denial Risk

    Mastopexy Without Medical Necessity

    Mastopexy is considered cosmetic when medical-necessity criteria are not met.

    Denial Risk

    Imaging Alone Does Not Confirm Malignancy

    Imaging modalities suggesting breast implant-associated malignancy are not sufficient to establish the diagnosis for coverage review.

    • Submit pathologic confirmation of BIA-ALCL or BIASCC from pre-operative percutaneous needle aspiration of a seroma or needle biopsy of a mass, if present.
    Billing Rule

    Contractual Cosmetic or Investigational Exclusion

    Applicable contract language controls coverage determinations. Contracts exclude services or procedures considered investigational or cosmetic, and providers may bill members for those services.

    • Inform members before rendering services that are considered investigational or cosmetic and that they are likely to be financially responsible for the cost.
    Cosmetic breast surgery
    PurposeSurgery intended to alter the appearance of a breast
    EnhancementSurgery intended to enhance the appearance of a breast
    Applicable breastA breast that does not have a significantly altered appearance due to surgery, accidental injury, or trauma