This document addresses the following three areas: reconstructive breast surgery, cosmetic surgeries designed to enhance the appearance of the breast and management of breast implants.

Reconstructive breast surgery refers to surgical procedures to rebuild the contour of the breast, along with the nipple and areola if desired. Typically, breast reconstruction is performed following a mastectomy (that is, the breast has been removed because of breast cancer) or lumpectomy (that is, removal of the breast tumor and tissue surrounding it), but occasionally techniques of breast reconstruction are used to treat individuals who have an abnormal development of one or both breasts. 

Note: Please see the following related document(s) for additional information:

• SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
• CG-SURG-71 Reduction Mammaplasty

Note: This document does not address gender affirming surgery or procedures. Criteria for gender affirming surgery or procedures are found in applicable guidelines used by the plan.

For autologous fat grafting and other soft tissue augmentation procedures of the breast see:

• MED.00132 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures

Note: The Women’s Health and Cancer Rights Act of 1998 (WHCRA) is federal legislation that provides that any individual, with insurance coverage who is receiving benefits in connection with a mastectomy covered by their benefit plan (whether or not for cancer) who elects breast reconstruction, must receive coverage for the reconstructive services as provided by WHCRA. This includes reconstruction of the breast on which the mastectomy has been performed, surgery and reconstruction of the other breast to produce a symmetrical appearance and prostheses and treatment of physical complications of all stages of the mastectomy including lymphedemas. If additional surgery is required for either breast for treatment of physical complications of the implant or reconstruction, surgery on the other breast to produce a symmetrical appearance is reconstructive at that point as well. The name of this law is misleading because: 1) cancer does not have to be the reason for the mastectomy; and 2) the mandate applies to men, as well as women. WHCRA does not address lumpectomies. Some states have enacted similar legislation, and some states include mandated benefits for reconstructive services after lumpectomy.

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant functional impairment, AND the procedure can be reasonably expected to improve the functional impairment.

Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect.

Note: Not all benefit contracts include benefits for reconstructive services as defined by this document. Benefit language supersedes this document.

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those that are primarily intended to preserve or improve appearance.

Position Statement

Medically Necessary:

Removal of implants partially or completely filled with Silicone Gel is considered medically necessary when there is documented implant rupture (that is, using mammography, ultrasound, or MRI).

Removal of a Silicone Gel filled, Saline filled or “Alternative” implant is considered medically necessary for any of the following:

1. Infection of the implant or surrounding tissue; or
2. Implant exposure/extrusion; or
3. Pain related to Baker Class IV capsular contracture; or
4. Confirmed cases of breast implant-associated anaplastic large cell lymphoma; or
5. Elective removal in individuals with an increased risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) due to use of Allergan BIOCELL textured breast implants and tissue expanders; or
6. Prior to surgical treatment of breast cancer. (Note: Implant explantation is routinely performed at the time of mastectomy. In individuals treated with breast conserving surgery [that is, lumpectomy], a breast implant may or may not interfere with subsequent treatment, and thus explantation at the time of lumpectomy is at the discretion of the treating physician and the treated individual).

Reconstructive:

Breast surgery is considered reconstructive to rebuild the normal contour of the affected and the contralateral unaffected breast to produce a more normal appearance following a mastectomy, lumpectomy, or other breast surgery for breast cancer.

Surgical procedures, such as reduction mammaplasty, may be considered reconstructive when done in advance of mastectomy or lumpectomy for breast cancer in order to produce improved cosmesis and prevent postoperative complications.

Breast surgery of both breasts is considered reconstructive following the mastectomy of both breasts.

Breast surgery to alter the contour of the breast is considered reconstructive when there are significant abnormalities related to trauma, congenital defects, infection or other non-malignant disease. A specific example of this is Poland syndrome which may be diagnosed when all of the following are present:

1. Congenital absence or hypoplasia of pectoralis major and minor muscles; and
2. Breast hypoplasia; and
3. Congenital partial absence of the upper costal cartilage.

Removal of an implant (any type) with or without reimplantation is considered reconstructive when:

1. An implant, originally placed in an individual with a history of mastectomy, lumpectomy or treatment of breast cancer for reconstructive purposes as defined above; and
2. There has been development of a visible distortion (Baker Class III contracture).  

Removal of a ruptured saline-filled or “Alternative" implant with or without reimplantation is considered reconstructive when originally placed in an individual with a history of mastectomy, lumpectomy or treatment of breast cancer for reconstructive purposes, as defined above.

Surgery on the contralateral breast to produce a symmetrical appearance after removal of an implant and reimplantation is considered reconstructive when the implant was originally placed for reconstructive purposes in an individual with a history of mastectomy, lumpectomy or treatment of breast cancer.

Not Medically Necessary:

Removal of a ruptured saline-filled or “Alternative” implant is considered not medically necessary since the potential adverse medical consequences of implant rupture are related to silicone gel implants only.

Removal of ANY TYPE of breast implant is considered not medically necessary for any of the following:

1. Systemic symptoms attributed to connective tissue disease, autoimmune diseases, etc.; or
2. Personal anxiety; or
3. Pain not related to contractures or rupture; or
4. The medically necessary or reconstructive criteria listed above have not been met.

Cosmetic and Not Medically Necessary:

Reimplantation of an implant inserted for cosmetic purposes only (that is, for reasons other than a history of mastectomy, lumpectomy, treatment of breast cancer, significant abnormalities related to trauma, congenital defects, infection or other non-malignant disease) and removed as part of a medically necessary or reconstructive surgery (see above) is considered cosmetic and not medically necessary. 

Other breast procedures, (including augmentation mammaplasty/breast lift, implant repositioning, repair of inverted nipples, mastopexy) are considered cosmetic and not medically necessary except when performed as part of a covered breast reconstruction service.