Prior authorization request form Form

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Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the member meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request preauthorization or post-payment review. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. This clinical policy is not intended to pre-empt the judgment of the reviewing medical director or dictate to health care providers how to practice medicine. Health care providers are expected to exercise their medical judgment in rendering appropriate care. Health care providers are expected to exercise their medical judgment in rendering appropriate care.
EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary.
If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. Identification of selected brand names of devices, tests and procedures in a medical coverage policy is for reference only and is not an endorsement of any one device, test or procedure over another. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication.
EmblemHealth may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. EmblemHealth Services Company, LLC, has adopted this policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC, and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc. . Definitions Breast augmentation A surgical procedure that increases the size and proportions of a woman’s breast. Breast implants Prosthetic devices (saline- or silicone gel-filled or biluminal) that are surgically inserted in the chest. Breast reconstruction A surgical procedure that restores the natural breast contour and mass following mastectomy, trauma, injury or congenital deformity (the latter indication is excluded from coverage; see Note, p. 2 and Cosmetic and Reconstructive Surgery Procedures policy). Capsular contracture A tightening of the capsule (scar tissue) surrounding an implant, resulting in firmness or hardening of the breast. Capsulectomy Surgical removal of the capsule. Capsulotomy (open) Incision or opening in the capsule made by an open surgical approach. Cosmetic surgery Reshaping normal structures of the body to improve the patient’s appearance and self-esteem.

Mastopexy Plastic surgery to move sagging breasts into a more elevated position. It involves the repositioning of the nipple and areola and is sometimes performed in conjunction with implant insertion. Reconstructive surgery Performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function but may also be done to approximate a normal appearance (e.g., post mastectomy for breast cancer; see Note, p. 2 and Cosmetic and Reconstructive Surgery Procedures policy). Tissue expander An adjustable implant that can be inflated with saline to stretch the tissue at the mastectomy site to create a new tissue flap for implantation of the breast implant. Related Medical Guidelines Cosmetic and Reconstructive Surgery Procedures Gender Reassignment Surgery Surgical Correction of Chest Wall Deformities Guideline Note:

The Plan abides by the federal Women’s Health and Cancer Rights Act, which provides protections to those patients who choose to have breast reconstruction following a mastectomy as well as the New York State Chest Wall Reconstruction Bill no. S07881.i
Requests for congenital deformity indications will be reviewed on a case-by-case basis. To facilitate coverage determination, please refer to the member's benefit package. If there is a discrepancy between this policy and a member’s plan of benefits, then the provision of the benefits will govern and rule. (See also Surgical Correction of Chest Wall Deformities)
A. Breast reconstruction procedures: Members are eligible for all the following procedures (which may be performed concurrently with a mastectomy/lumpectomy or at any time postoperatively):  Reconstruction of postmastectomy or traumatically injured breast  Reconstruction of the nondiseased (contralateral) breast for symmetry
 Reconstruction with tissue expansion, implant insertion, or tissue flap transfer only following: • Mastectomy or lumpectomy secondary to breast disease • Traumatic injury
 In certain women with macromastia and/or breast ptosis that are planned for nipple sparing mastectomy for a genetic mutation (such as BRCA1 or 2, etc) and/or an elevated risk of breast cancer it is medically necessary to perform a preparatory mastopexy or reduction mammaplasty prior to the mastectomy.
When implant insertion is solely for breast size enlargement, the procedure is deemed cosmetic. B. Breast implant removal:ii Members are eligible for coverage of implant removal (regardless of the etiology of initial implant) when any of the following conditions exist:  Implant extrusion

 Implant ruptureiii (objective evidence of implant rupture, such as mammogram, MRI or ultrasound must be submitted for review. To confirm the presence of Baker IV classification, photos must be also provided.) (Endnote is specific to silicone implants; for information specific to the removal of saline implants, see Limitations/Exclusions)  Infection.  Baker IV capsular contracture (Table 1)  Implant is textured (e.g., Allergan® BIOCELL) (Removal is considered medically necessary regardless of reason for initial placement due to an increased risk of breast cancer related to Anaplastic Large Cell Lymphoma) Table 1: The Baker Classification System for Capsular Contracture Class I Augmented breast feels soft as a normal breast. Class II Augmented breast is less soft and the implant can be palpated but is not visible. Class III Augmented breast is firm and palpable and the implant (or distortion) is visible. Class IV Augmented breast is hard, painful, cold, tender and distorted.

Documentation The following documentation must be supplied to the Plan for authorization consideration:  Original indication for implantation and current symptoms.
 Imaging study, i.e., mammography, MRI or ultrasonography (for demonstration of rupture). Limitations and Exclusions  Breast reconstruction: Fat grafting — the plan considers harvesting (via of lipectomy or liposuction) and grafting of autologous fat as a replacement for implants for breast reconstruction, or to fill defects after breast conservation surgery or other reconstructive techniques medically necessary.  Breast reconstruction revision (eff. 01/01/2023): As per the American Medical Association (AMA) breast repair and/or reconstruction introductory guidelines, “if a limited procedure is performed with a defined code (eg, scar revision), then the more specific code should be used.” If code 19380 is reported, no other codes should be reported for work related to the breast envelope (ie, scar revision, mastopexy, liposuction, capsule modification, etc). Exchanging an implant for a new, different size, shape, or type of implant (19342), or autologous fat grafting for increased volume or contour irregularities (15771, 15772), may be reported separately.  Autoimmune disease: The plan does not cover silicone implant removal if autoimmune disease was diagnosed in the presence of silicone implant, as no causal relationship has been established between silicone implants and the development of the disease.  Implant removal:
• Implant removal in the presence of documented medical necessity (as indicated above) is a covered benefit; however, the plan does not cover any subsequent implant procedure unless the original insertion was a component of a medically necessary reconstruction.

• 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. • “Breast implant illness” or “silicone implant illness” are not medically necessary indications for breast implant removal, as there are no evidence-based studies or peer-reviewed data concerning the formation of a new syndrome.
• Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure. An assumption of same anatomic site is made during the auditing process. Site specific modifiers may be used to denote the performance of these procedures at different anatomic sites. Therefore, intact mammary implant removal (CPT code 19328) and mammary implant material removal (CPT code 19330) will be considered incidental services performed under capsulotomy (CPT code 19370) and capsulectomy (CPT code 19371) procedures within the same operative session.  Implant reinsertion: The plan does not cover reinsertion unless the original placement was part of a reconstruction. If the implant was originally placed for a condition not listed in the Guideline section above, then the reinsertion is cosmetic and not considered medically necessary.
 Mastopexy: Mastopexy is covered when associated with a reconstructive procedure. Procedure Codes 11920 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less 11921 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm 11922 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure) 15734 Muscle, myocutaneous, or fasciocutaneous flap; trunk 15756 Free muscle or myocutaneous flap with microvascular anastomosis 15777 Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (eg, breast, trunk) (List separately in addition to code for primary procedure) 15769 Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia) 19303 Mastectomy, simple, complete 19316 Mastopexy 19318 Breast reduction 19325 Breast augmentation; with implant 19328 Removal of intact breast implant
19330 Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel) 19340 Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel)
19342 Insertion or replacement of breast implant on separate day from mastectomy

19350 Nipple/areola reconstruction 19355 Correction of inverted nipples 19357 Tissue expander placement in breast reconstruction, including subsequent expansion(s) 19361 Breast reconstruction with latissimus dorsi flap 19364 Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap) 19366 Breast reconstruction with other technique
19367 Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap 19368 Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging)
19369 Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap
19370 Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy 19371 Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents
19380 Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction)
19396 Preparation of moulage for custom breast implant L8600 Implantable breast prosthesis, silicone or equal L8033 Nipple prosthesis, custom fabricated, reusable, any material, any type, each
S2066 Breast reconstruction with gluteal artery perforator (GAP) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral S2067
Breast reconstruction of a single breast with "stacked" deep inferior epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator (GAP) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateral S2068* Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral

*S2066-S2068 are not accepted to report breast reconstruction via a free flap, providers should use 19364 instead.
Please see our CPT and HCPCS Billing Guidelines Reimbursement Policy for complete guidance:
https://www.emblemhealth.com/providers/claims-corner/reimbursement-policies
ICD-10 Diagnoses C50.011 Malignant neoplasm of nipple and areola, right female breast C50.012 Malignant neoplasm of nipple and areola, left female breast C50.019 Malignant neoplasm of nipple and areola, unspecified female breast C50.111 Malignant neoplasm of central portion of right female breast C50.112 Malignant neoplasm of central portion of left female breast C50.119 Malignant neoplasm of central portion of unspecified female breast C50.211 Malignant neoplasm of upper-inner quadrant of right female breast

C50.212 Malignant neoplasm of upper-inner quadrant of left female breast C50.219 Malignant neoplasm of upper-inner quadrant of unspecified female breast C50.311 Malignant neoplasm of lower-inner quadrant of right female breast C50.312 Malignant neoplasm of lower-inner quadrant of left female breast C50.319 Malignant neoplasm of lower-inner quadrant of unspecified female breast C50.411 Malignant neoplasm of upper-outer quadrant of right female breast C50.412 Malignant neoplasm of upper-outer quadrant of left female breast C50.419 Malignant neoplasm of upper-outer quadrant of unspecified female breast C50.511 Malignant neoplasm of lower-outer quadrant of right female breast C50.512 Malignant neoplasm of lower-outer quadrant of left female breast C50.519 Malignant neoplasm of lower-outer quadrant of unspecified female breast C50.611 Malignant neoplasm of axillary tail of right female breast C50.612 Malignant neoplasm of axillary tail of left female breast C50.619 Malignant neoplasm of axillary tail of unspecified female breast C50.811 Malignant neoplasm of overlapping sites of right female breast C50.812 Malignant neoplasm of overlapping sites of left female breast C50.819 Malignant neoplasm of overlapping sites of unspecified female breast C50.911 Malignant neoplasm of unspecified site of right female breast C50.912 Malignant neoplasm of unspecified site of left female breast C50.919 Malignant neoplasm of unspecified site of unspecified female breast D05.00 Lobular carcinoma in situ of unspecified breast D05.01 Lobular carcinoma in situ of right breast D05.02 Lobular carcinoma in situ of left breast D05.10 Intraductal carcinoma in situ of unspecified breast D05.11 Intraductal carcinoma in situ of right breast D05.12 Intraductal carcinoma in situ of left breast D05.80 Other specified type of carcinoma in situ of unspecified breast D05.81 Other specified type of carcinoma in situ of right breast D05.82 Other specified type of carcinoma in situ of left breast D05.90 Unspecified type of carcinoma in situ of unspecified breast D05.91 Unspecified type of carcinoma in situ of right breast D05.92 Unspecified type of carcinoma in situ of left breast N64.89 Other specified disorders of breast N65.0 Deformity of reconstructed breast N65.1 Disproportion of reconstructed breast T85.41xA Breakdown (mechanical) of breast prosthesis and implant, initial encounter T85.42xA Displacement of breast prosthesis and implant, initial encounter

T85.43xA Leakage of breast prosthesis and implant, initial encounter T85.44xA Capsular contracture of breast implant, initial encounter T85.49xA Other mechanical complication of breast prosthesis and implant, initial encounter T85.79xA Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter Z45.811 Encounter for adjustment or removal of right breast implant Z45.812 Encounter for adjustment or removal of left breast implant Z45.819 Encounter for adjustment or removal of unspecified breast implant Z90.10 Acquired absence of unspecified breast and nipple Z90.11 Acquired absence of right breast and nipple Z90.12 Acquired absence of left breast and nipple Z90.13 Acquired absence of bilateral breasts and nipples References American Society of Plastic Surgeons. ASPS Recommended Insurance Coverage Criteria for Third-Party Payers Breast Reconstruction Following Diagnosis and Treatment for Breast Cancer. Sept. 2018. https://www.plasticsurgery.org/for-medical-professionals/health- policy/recommended-insurance-coverage-criteria. Accessed March 13, 2026. FDA. Breast Implants. December 2023. https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/default.htm. Accessed March 13, 2026. Rohrich RJ, Kaplan J, Dayan E. Silicone Implant Illness: Science versus Myth? Plast Reconstr Surg. 2019 Jul;144(1):98-109.
Kaplan J, Rohrich R. Breast implant illness: a topic in review. Gland Surg. 2021 Jan;10(1):430-443. Keane G, Chi D, Ha AY, Myckatyn TM. En Bloc Capsulectomy for Breast Implant Illness: A Social Media Phenomenon? Aesthet Surg J. 2021 Mar 12;41(4):448-459
National Comprehensive Care Network (NCCN) Clinical Practice Guidelines in Oncology. T-cell Lymphomas. Version 2.2026. https://www.nccn.org/professionals/physician_gls/pdf/t-cell.pdf. Accessed March 13, 2026. FDA. Questions and Answers about Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). Oct. 2019. https://www.fda.gov/medical-devices/breast-implants/questions-and-answers-about-breast-implant-associated-anaplastic-large- cell-lymphoma-bia-alcl. Accessed March 13, 2026. Specialty-matched clinical peer review.
Revision History Company(ies)

  DATE

REVISION EmblemHealth Apr. 20, 2026 Text regarding removal of textured implants was relocated from Limitations/Exclusions to the Guideline section EmblemHealth Mar. 13, 2026 Added coverage for removal of textured implants EmblemHealth Oct. 6, 2025 Added not pertaining to HCPCS codes S2066, S2067, and S2068 redirecting users to applicable Reimbursement Policy EmblemHealth Mar. 14, 2025 Transferred policy content to individual company branded template EmblemHealth Jun. 14, 2024 Removed language communicating that a capsulectomy is not medically necessary for saline implant removal

ConnectiCare EmblemHealth ConnectiCare Mar. 8, 2024 Added language pertaining to tissue flap transfer, lumpectomy and nipple-sparing to section delineating reconstruction procedures Added “noncontrast” to MRI within footnote delineating the best noninvasive test for silicone implant rupture EmblemHealth ConnectiCare Oct. 17, 2022 Added information pertaining to New York State Chest Wall Reconstruction Bill no. S07881 Added billing instructions commensurate with the AMA’s breast repair and/or reconstruction introductory guidelines EmblemHealth ConnectiCare Oct. 8, 2021 Added to Limitations Exclusions:

“Breast implant illness” or “silicone implant illness” are not medically necessary indications for breast implant removal, as there are no evidence- based studies or peer-reviewed data concerning the formation of a new syndrome
Removal of textured implants due to fear of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is not a medically necessary indication for breast implant removal EmblemHealth ConnectiCare Nov. 11, 2020 Added positive-coverage language for fat grafting (removing investigational designation) ConnectiCare Nov. 15, 2019 ConnectiCare adopts the clinical criteria of its parent corporation Emblem Health EmblemHealth Aug. 22, 2019 Added language that defines incidental services pertaining to implant removal EmblemHealth Nov. 11, 2016
Added link to EmblemHealth Medical Guideline Surgical Correction of Chest Wall Deformities. EmblemHealth Oct. 9, 2015 Amended Limitations/Exclusions section to communicate that removal of ruptured saline implants is not medically necessary.

i The Women’s Health and Cancer Rights Acts of 1998 is a federal law that provides protections to patients who choose to have breast reconstruction in connection with a mastectomy. The law stipulates that coverage must be provided for reconstruction of the breast on which the mastectomy has been performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prosthesis (e.g., breast implant) and treatment for physical complications of the mastectomy, including lymphedema. New York State Chest Wall Reconstruction Bill no. S07881 mandates chest wall reconstruction surgery which includes aesthetic flap closure. ii According to the American Society of Plastic Surgeons (ASPS), capsulectomy (removal of the scar capsule surrounding the implant) and the removal of trouble-free implants are not generally recommended, as the FDA has stated that removal carries a potentially greater risk than leaving these devices in place. Additionally, removal of the prosthesis may result in additional scarring. iii Rupture is defined as a physical disruption of the solid silicone elastomer shell of a silicone gel implant which results in the migration of silicone gel out of the implant on a macroscopic level (not to be confused with gel bleed). It is also recommended that the medical record specify how the implant rupture is documented (e.g., obvious distortion or deformity on physical examination or a history of change in

size and shape of the implant associated with confirmation by noninvasive testing of implant rupture, either intra- or extracapsular; the best noninvasive test for silicone gel implant rupture is noncontrast MRI).

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