Breast Implant Removal

Breast implantation surgery is performed for cosmetic breast augmentation, breast reconstructive surgery following mastectomy, replacement of implants, or augmentation/reconstruction of congenital defects or anomalies. There are currently only two types of breast implants. Saline breast implants consist of a silicone elastomer rubber-like shell filled with medical grade saline. Silicone-gel implants are made of an inner transparent silicone center surrounded by a silicone elastomer envelope. Some silicone-gel implants have a second fluorosilicone barrier to reduce the chance of leakage. Studies have indicated that intact silicone breast implants do not increase the risk of connective tissue disease or autoimmune disease.

POLICY

Removal of breast implant(s) for documented leakage from a silicone-gel breast implant is considered medically necessary. (See Medical Appropriateness below).
Reconstruction following removal of a leaking implant (i.e., silicone-gel or saline) is considered medically necessary. (See Applicable Tennessee State Mandate Requirements and Medical Appropriateness below.)
A capsulectomy as a part of implant removal and reconstruction is considered medically necessary. (See Applicable Tennessee State Mandate Requirements and Medical Appropriateness below.)
Removal of breast implant(s) for documented leakage from a saline breast implant done for cosmetic purposes is considered cosmetic. (See note under Additional Information.)
Reconstruction following removal of a leaking breast implant originally placed for cosmetic purposes is considered cosmetic.
Since intact silicone breast implants pose no health risk, removal of an intact implant is considered cosmetic.

MEDICAL APPROPRIATENESS

Removal of breast implant(s) is considered medically appropriate if 1 or more of the following are met:
- Removal of breast implant(s) if ALL of the following are met:
  - Documentation of 1 or more of the following:
    - Leakage from a silicone-gel breast implant and ALL of the following:
      - Confirmed leakage by 1 or more of the following:
        
        Magnetic resonance imaging (MRI)
        
        Mammogram
        
        Ultrasound
    - Leakage from a saline breast implant and ALL of the following:
      - Confirmed leakage by 1 or more of the following:
        
        Observed loss of size of the breast in a short period of time
        
        Observed loss of shape of the breast in a short period of time
        
        The original surgery was as a result of a mastectomy (not including lumpectomy)
      - Documentation of 1 or more of the following:
        
        Original surgery treated diseased breast(s)
        
        Original surgery treated non-diseased breast to establish symmetry
  - No contraindications including ABSENCE of ALL of the following:
    - Original saline breast implant(s) were placed for cosmetic purposes
    - Removal of intact silicone breast implants
- Reconstruction if ALL of the following are met:
  - The original procedure was considered a medically necessary and appropriate reconstructive surgical procedure (i.e., breast reconstruction following mastectomy)
  - Following removal of 1 or more of the following:
    - Leaking silicone-gel implant
    - Leaking saline implant
  - Surgery is performed on 1 or more of the following:
    - Diseased breast
    - Non-diseased breast to establish symmetry between the two breasts
  - No contraindications including ABSENCE of ALL of the following:
    - Leaking breast implant(s) originally placed for cosmetic purposes
    - Surgery on the non-diseased breast to establish symmetry is more than five (5) years from the date the reconstructive breast surgery was performed on the diseased breast
- Capsulectomy if ALL of the following are met:
  - The original implant was considered a medically necessary and appropriate reconstructive surgical procedure (i.e., breast reconstruction following mastectomy)
  - Performed as part of the implant removal and reconstruction
  - Planned removal of 1 or more of the following:
    - Silicone-gel implant
    - Saline implant

APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS

The provisions of this mandate concerning reconstructive breast surgery, Tennessee Code Annotated, Title 56, Chapter 7, Part 2507 read as follows:

Any individual, franchise, blanket or group health insurance policy, medical service plan, contract, hospital service corporation contract, hospital and medical service corporation contract, fraternal benefit society, health maintenance organization, or managed care organization that provides coverage for mastectomy surgery shall provide coverage for all stages of reconstructive breast surgery on the diseased breast as a result of a mastectomy, but not including a lumpectomy, as well as any surgical procedure on the nondiseased breast deemed necessary to establish symmetry between the two (2) breasts in the manner chosen by the patient and physician. The surgical procedure performed on a nondiseased breast to establish symmetry with the diseased breast must occur within five (5) years of the date the reconstructive breast surgery was performed on a diseased breast.

IMPORTANT REMINDERS

Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g., statement.

We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.

ADDITIONAL INFORMATION

Documentation/verification of a leaking saline breast implant is by observation of loss of size or shape of the breast in a short period of time.

In accordance with State and Federal mandates, removal and replacement of a leaking saline implant would be appropriate if the original surgery was a result of a mastectomy (not including lumpectomy). The surgery on the non-diseased breast to establish symmetry between the two breasts in a manner chosen by the individual and the physician would also be appropriate according to State and Federal mandates.

SOURCES

Centers for Medicare & Medicaid Services. CMS.gov. NCD for breast reconstruction following mastectomy (140.2). Retrieved August 27, 2019 from https://www.cms.gov/.

Centers for Medicare & Medicaid Services. CMS.gov. The Center for Consumer Information & Insurance Oversight. Women’s health and cancer rights act (WHCRA). Retrieved June 16, 2025 from https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/whcra_factsheet.html.

Tennessee Code: Title 56 Insurance: Chapter 7 Policies and Policyholders: Part 25 Mandated Insurer or Plan Options: 56-7-2507. Reconstructive breast surgery. Retrieved June 16, 2025 from http://www.lexisnexis.com/hottopics/tncode/.

ORIGINAL EFFECTIVE DATE: 11/1989

MOST RECENT REVIEW DATE: 3/10/2026

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

This document has been classified as public information.