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.
Removal of breast implant(s) for documented leakage from a silicone-gel breast implant is considered medically necessary. (See note under Additional Information.)
Reconstruction following removal of a leaking implant (i.e., silicone-gel or saline) if the original procedure was considered a medically necessary and appropriate reconstructive surgical procedure (i.e., breast reconstruction following mastectomy) will be considered medically necessary. (See Applicable Tennessee State Mandate Requirements below.)
If the original implant (silicone-gel or saline) was considered a medically necessary and appropriate reconstructive surgical procedure, a capsulectomy as a part of implant removal and reconstruction is considered medically necessary. (See Applicable Tennessee State Mandate Requirements 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.
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.
Documentation/verification of leakage of a silicone-gel breast implant must be performed by magnetic resonance imaging (MRI), mammogram, or ultrasound.
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.
Centers for Medicare & Medicaid Services. CMS.gov. NCD for breast reconstruction following mastectomy (140.2). Retrieved November 21, 2017 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 November 21, 2017 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 October 5, 2018 from http://www.lexisnexis.com/hottopics/tncode/.
ORIGINAL EFFECTIVE DATE: 11/1989
MOST RECENT REVIEW DATE: 11/8/2018
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.
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