BlueCross and BlueShield of Montana Medical Policy/Codes
Breast Implant, Removal and/or Insertion
Chapter: Surgery: Procedures
Current Effective Date: April 01, 2014
Original Effective Date: September 24, 2013
Publish Date: January 13, 2014
Revised Dates: January 13, 2014
Description

Breast implant, removal and/or insertion, is a surgical removal or replacement of either a silicone gel-filled or a saline-filled breast implant with a new implant. The most common is insertion of a breast implant, either a silicone gel-filled or saline-filled prosthesis. The implant is either inserted immediately at the time of mastectomy or sometime afterward in conjunction with the previous use of a tissue expander. Breast implants are used to augment breast size for cosmesis. The U.S. Food and Drug Administration (FDA) updates and summaries estimate 5 to 10 million women worldwide have breast implants. (1)

Breast implants are not lifetime devices. The longer a woman has implants, the more likely it is she will need to have surgery to remove or replace them. (2) Local complications of breast implants are frequent and may require removal of the implant. The FDA has released several documents for patients and healthcare providers. (1-4) According to the FDA, the following is a listing of local complications and adverse outcomes that occur in 1% or more of patients at any time after breast implant surgery done for reconstructive purposes or cosmesis:

  • Asymmetry or breasts are uneven in appearance in terms of size, shape, or breast level,
  • Breast feeding difficulties,
  • Breast pain, sagging or ptosis, or tissue atrophy,
  • Calcification or calcium build-up in breast tissue,
  • Capsular contracture, hardening of the breast area around the implant (see Baker Classification below),
  • Chest wall and underlying rib cage deformity,
  • Deflation or leakage of breast implant,
  • Delayed wound healing,
  • Extrusion of implant appears through the skin, which breaks down,
  • Hematoma,
  • Iatrogenic injury or damage to the tissue as a result of implant surgery,
  • Implant displacement, malposition, palpability, visibility, wrinkling, or rippling,
  • Infection,
  • Inflammation or irritation,
  • Necrosis,
  • Nipple changes,
  • Redness or bruising,
  • Rupture of implant,
  • Scarring,
  • Seroma, collection of fluid around the implant,
  • Skin rash,
  • Swollen or enlarged lymph nodes, and/or
  • Unsatisfactory appearance due to implant style or size.

Contracture, the most common local complication of breast implants, is hardening of breast tissue around the implant that can result in tightness and pain. Contractures have been graded according to the Baker Classification as follows:

Grade I:           Augmented breast feels soft as a normal breast.

Grade II:         Breast is less soft and the implant can be palpated but is not visible.

Grade III:        Breast is firm, palpable, and the implant (or its distortion) is visible.

Grade IV:        Breast is hard, painful, cold, tender, and distorted.

The FDA is aware of approximately 60 cases reports worldwide of anaplastic large cell lymphoma (ALCL) in women with breast implants. (4-7) ALCL is a rare type of non-Hodgkin’s lymphoma or cancer involving the cells of the immune system. In women with breast implants, ALCL is found in the tissue next to the implant itself and is usually contained within the fibrous capsule that the body forms naturally around the implant. The FDA studies focused on cases of ALCL in 34 women with silicone gel-filled or saline-filled implants. Although ALCL is extremely rare, according to the FDA, the agency believes that patients with implants may have a very small but increased risk of developing this disease in the scar tissue adjacent to the implant. The National Cancer Institute has estimated 1 in 500,000 women per year in the U.S. are diagnosed with ALCL. However, ALCL in the breast is even rarer; an estimated 3 in 100 million women per year will be diagnosed.

Regulatory Status

Several breast implants have received approval for use as part of breast reconstructive procedures or cosmesis from the FDA (8). As of September 2013, the following medical devices have been approved for augmentation or reconstruction patients:

  • Silicone gel-filled breast implants:
    • Mentor® MemoryGel Silicone Gel-Filled Breast Implants (FDA-approved in 2009),
    • Allergan Natrelle® Silicone Gel-Filled Breast Implants (FDA-approved in 2009),
    • Sientra® Silicone Gell Breast Implants (FDA-approved in 2012), and
    • Allergan Natrelle® 410 Highly Cohesive Anatomically Shaped Silicone-Filled Breast Implants (FDA-approved in 2013).
  • Saline-filled breast implants:
    • Allergan (formerly Inamed) Natrelle® Saline Breast Implants (FDA-approved in 2004 and again in 2005), and
    • Mentor® Saline Breast Implants (FDA-approved in 2009).
Policy

Prior authorization is NOT recommended for breast reconstruction for members with a personal history of breast cancer.

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Many contracts have exclusions for services or supplies provided as a result of complications following a non-covered procedure. For example, none of the services listed below would be covered for a cosmetic breast implant augmentation (unilateral or bilateral) which is unrelated to post mastectomy reconstruction with contralateral breast surgery, post accidental injury or trauma:

  • Diagnostic evaluation, OR
  • Preparation for surgery, OR
  • Services or supplies provided in conjunction with treatment,  OR
  • Removal of implant, OR
  • Replacement insertion of implant.

To determine coverage for removal of a breast implant* – with or without replacement of a breast implant* – utilize the following statements in tandem with the GRID that follows:

  • Breast implant services are considered not medically necessary (NMN) when provided as a part of breast reconstructive surgery and the clinical condition poses no health threat or risk to the patient. (Those not allowed services are identified in the grid by “NMN”, which includes imaging of breast implants when the original breast implant was done as part of breast reconstructive steps.)
  • Breast implant services may be considered a cosmetic exclusion (CE) when originally performed for cosmetic breast augmentation. (Those cosmetic exclusion services are identified in the grid by “CE”, which includes the CE designation for imaging of breast implants when the original breast implant was done for cosmetic breast augmentation.)

*   NOTE: Breast implant refers to either silicone gel-filled OR saline-filled product.

Clinical Conditions

Post Reconstructive Implant Removal

(*see NOTE)

Post Reconstructive Implant Reinsertion or Replacement (*see NOTE)

Post Cosmetic Implant Removal (**see NOTE)

Post Cosmetic Implant Reinsertion or Replacement (**see NOTE)

Documented surgical treatment of breast cancer whether a silicone gel-filled or saline-filled implant(s)

Mandated Benefit

Mandated Benefit

Requires Medical Review

Requires Medical Review

Recurrent breast infection related only to contracture from or rupture of silicone gel-filled or  saline-filled implant

Mandated Benefit

Mandated Benefit

CE

CE

Imaging evidence of silicone gel-filled or saline-filled implant rupture

Mandated Benefit

Mandated Benefit

CE

CE

Imaging evidence of extrusion of silicone gel-filled or saline-filled contents into the subcutaneous tissue

Mandated Benefit

Mandated Benefit

CE

CE

Baker Class III or IV contracture as a result of a silicone gel-filled or  saline-filled implant

Mandated Benefit

Mandated Benefit

CE

CE

Baker Class II contracture as a result of a silicone gel-filled or  saline-filled implant

NMN

NMN

CE

CE

Baker Class I augmented breast feels as soft as a normal breast whether a silicone gel-filled or saline-filled implant

NMN

NMN

CE

CE

Chronic breast pain related ONLY to recurrent breast infection, contracture from, or rupture of a silicone gel-filled or  saline-filled implant

NMN

NMN

CE

CE

Breast or chest wall pain unrelated to contractures or rupture.

NMN

NMN

CE

CE

Patient anxiety or fear of silicone gel-filled or saline-filled implant(s) rupture and/or contracture.

NMN

NMN

CE

CE

Patient anxiety or fear of cancer risk, including but not limited to anaplastic large cell lymphoma (ALCL), associated with components of implant envelope (sleeve or covering) or contents of the implant whether silicone gel-filled or saline-filled implant.

NMN

NMN

CE

CE

Patient anxiety or fear of potential systemic conditions from silicone gel-filled or saline-filled implant, such as:

  • Connective tissue disease, OR
  • Autoimmune disease, OR
  • Rheumatic conditions, OR
  • Neurologic symptoms, OR
  • Fibromyalgia, OR
  • Chronic fatigue syndrome.

NMN

NMN

CE

CE

GRID acronyms:

  • NMN – not medically necessary
  • CE – cosmetic exclusion

* NOTE: Reconstructive removal with or without replacement or reinsertion of silicone gel-filled or saline-filled implant(s) when the initial surgery was due to cancer or an approved prophylactic mastectomy for a benign disease (such as cancer risk). There are some instances where reconstructive use of a breast implant has been done following trauma or accident. Refer to Medical Policy (SUR716.011) Reconstructive and Contralateral Mammaplasty for explanation of coverage regarding breast implants following breast surgery for cancer on the affected and unaffected breast.

** NOTE: Cosmetic removal with or without replacement or reinsertion of silicone gel-filled or saline filled implant, unrelated to cancer or cancer risk, trauma, or accident, are intended primarily to improve physical appearance, performed primarily for psychological purposes and/or to restore form that does not correct or materially improve a bodily function. Refer to Medical Policy (SUR716.001) Cosmetic and Reconstructive Surgery for explanation of coverage.

Documentation may be required to review requests or claims for breast implant(s) surgery, including, but not limited to, indications such as breast implant rupture or extrusion. Examples of documentation include but are not limited to at least two of the following:

  • Photographs, or
  • Imaging using mammography, magnetic resonance imaging, or ultrasonography, or
  • Consultations, or
  • Operative reports and/or other applicable hospital records, such as, laboratory or pathology report(s), history and physical, and/or             
  • Treating provider’s office records.

Refer to Medical Policy – Breast Magnetic Resonance Imaging (BMRI) for explanation of coverage for imaging when magnetic resonance imaging is utilized.

Rationale

This section of the current policy has been substantially revised. Following is a summary of the key literature to date.

Complications of breast implants are common and may require removal. (9) Determining medical necessity of removal requires documentation of the type of implant and its original indication for initial insertion or placement, such as whether cosmetic or reconstructive. Since the purpose of reconstructive implants is the restoration of normal breast appearance following treatment of cancer, there are small subsets of patients requiring restoration of normal breast appearance following treatment of accident or trauma. This small subset may experience complications of breast implants and may require removal. However, removal of cosmetic implants, whether clinical conditions appear or not, are not a covered benefit as their initial placement was a cosmetic augmentation procedure which was not a covered benefit. Patients who have originally undergone implantation of a cosmetic breast implant are not candidates for additional re-insertion of another breast implant or any form of reconstructive breast surgery after the implant has been removed.

Post implant insertion complications can be subdivided into local or systemic complications.

Local complications include implant contracture, rupture, extrusion, and/or infection. Extrusion or infection is considered a medical indication for possible removal. Documented rupture of a silicone gel-filled implant is considered medical indication for removal in cases where the implant was originally done as a reconstructive treatment. However, saline-filled implant rupture is not considered an absolute medical indication for removal, except in cases where the original indication for implant insertion was done as a reconstructive treatment. Since normal saline is physiologic, rupture and extrusion does not pose a health risk; thus, removal of saline-filled implants are not medically necessary for patients with cosmetic implants.

Rupture of the breast implant may be difficult to document, but physical exam, mammography, ultrasonography, or magnetic resonance imaging has been used. There is no consensus on which method affords the best sensitivity and specificity. (10-12) Although it has been suggested that older implants are associated with a higher incidence of rupture, there is no consensus that screening implants for rupture is warranted. Specifically, in the hearings on breast implants by the U.S. Food and Drug Administration (FDA), held in 1992, the FDA did not recommend screening for asymptomatic ruptures. Instead, workup for a potential rupture is typically initiated at the onset of local symptoms, such as sudden change in the size or consistency of an implant, or the development of local pain. Documentation of rupture is considered an absolute requirement for possible removal in all cases, whether the implant was originally cosmetic or reconstructive.

Local complications of breast implants are frequent and may require removal of the implant. Contracture is the most common local complication of breast implants. Contractures are somewhat subjective findings, and can be graded according to the Baker classification explained earlier in the Description portion of this policy. (13) Contractures are ranked from Grade I (a normal breast with implant) to Grade IV (a breast with implant that is hard, cold, painful, tender, and distorted). Grade IV contractures interfere with adequate mammography screening and are the cause of local symptoms, and thus their presence constitutes a health risk. (14) Therefore, removal may be considered medically necessary when the implant was originally inserted for reconstructive purposes. Grade III contractures, which describe firm, palpable implants, do not interfere with mammography; therefore, removal of these implants is not considered an absolute indication for removal. However, since Grade III contractures have an impact on the normal appearance of the breast, removal may be appropriate in implants inserted for reconstructive purposes, since the goal of restoration of the normal appearance of the breast is not achieved.

Potential systemic complications of implants, most prominently various connective tissue diseases or chronic fatigue syndrome, has been controversial in the past. In particular, it had been hypothesized that leakage of silicone, due to either an implant rupture or to “bleeding of silicone through an intact capsule, may incite an autoimmune response with the development of systemic symptoms. However, to date, large epidemiologic studies have not demonstrated that women with breast implants are over represented among all those with connective tissue disease. (15-18) In addition, there are inadequate empiric studies to demonstrate that removal of breast implants is associated with resolution of systemic symptoms. As a result of this evidence, there is not considered to be a relationship between silicone breast implants and systemic disease, particularly connective tissue disease.

Patients with cosmetic implants may develop breast cancer. While lumpectomy can be accomplished without removal of the implant, cosmetically place implants removed an adjunct to surgical treatment for breast cancer is not a covered benefit, as the initial placement was not a covered benefit. However, implant removal is not necessary in patients who are undergoing chemotherapy or radiation therapy for breast cancer.

An ECRI Health Technology Assessment on the cancer risk and silicone gel-filled implants was completed in 2012. (19) After the FDA mandated all silicone gel-filled devices be removed from the market in 1992, but still allowed for use for patients undergoing reconstruction post mastectomy; the FDA required more robust study of safety and effectiveness of breast implants for the premarket approval process. Studies reviewed described a link between cancer, rheumatologic/neurologic disorders, and autoimmune diseases. The U.S. Congress directed the National Institutes of Health (NIH) to perform a large follow-up study to review the long-term effects of breast implants, focusing in part on the association of cancer for patients with breast implants. (20-21) The 2000 National Cancer Institute of the NIH reported on 13,500 women who had undergone bilateral breast implant surgery between 1962 and 1989. There were 2 control groups: 1.) women of similar age who underwent other plastic surgeries, and 2.) women in the general population. The study group concluded that there was no cancer risk in women with breast implants.

In January 2011, the FDA released a recommendation that patients with breast implants, either silicone gel-filled or saline-filled, suspected or diagnosed with anaplastic large cell lymphoma (ALCL), a rare subgroup of non-Hodgkin lymphoma, be referred to a specialist for evaluation. (7) The FDA reported, “Data reviewed by the FDA suggest that patients with breast implants may have a very small but significant risk of ALCL in the scar capsule adjacent to the implant.” The FDA has requested health care professionals report any confirmed cases of ALCL in women with breast implants. The FDA did not recommend removal of the breast implants, but did recommend to patients to monitor their implants and report any changes to their physician.

Additionally, in 2012, ECRI completed another literature review focusing on non-cancerous risks and adverse outcomes associated with using silicone gel-filled breast implants. (22) The most common adverse outcomes were capsular contracture, implant rupture, asymmetry of breast appearance, scarring, pain, and/or infection. According to ECRI and the FDA, there is no evidence linking silicone gel-filled breast implants can cause reproductive health conditions or connective tissue diseases, such as rheumatoid arthritis.

Once an implant has been removed, patients who have originally undergone reconstructive implantation are candidates for additional reconstructive breast surgery, either insertion of another breast implant, or for autologous reconstruction of the breast. Patients who have originally undergone implantation of a cosmetic breast implant are not candidates for additional reconstructive breast surgery after breast implant removal.

Summary

Breast implants can be used as part of breast reconstruction, or for cosmetic reasons. Local complications of breast implants are common, and may lead to breast implant removal. The medical necessity of implant removal is dependent on the type of implant, the indication for removal, and the original indication for implantation. Removal of cosmetically inserted implants, whether complications (including cancer) appear or not, or patient has concerns, fears, or believes there is risk of any potential complication, are not a covered benefit, as the initial placement was not a covered benefit.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

85.53, 85.54, 85.93, 85.94, 174.0-174.8, 233.0 611.0, 611.71, 611.72, 611.8, 686.1, 909.3, 996.54, 996.69, 996.79, 998.51, 998.59, 998.83, V10.3, V16.3, V45.71, V50.1, V50.41, V51

ICD-10 Codes

C50.011- C50.019; C50.211-C50.219; C50.311-C50.319; C50.411-C50.419; C50.511-C50.519; C50.611-C50.619; C50.811-C50.812; C50.911-C50.919 , D05.01-D05.99, T85.41-T85.49, Z80.3, Z85.3, T85.71xA-T85.79xS, T85.81xA-T85.89xS, T85.698xA-T85.698xS, 0HBU0ZZ, 0HBV0ZZ, 0H0T07Z, 0H0T0JZ, 0H0T0KZ, 0H0T0ZZ, 0H0U07Z, 0H0U0JZ, 0H0U0KZ, 0H0U0ZZ, 0H0V07Z, 0H0V0JZ, 0H0V0KZ, 0H0V0ZZ, 0HRT0JZ, 0HRT075, 0HRT076, 0HRT077, 0HRT078, 0HRT079, 0HRU07Z, 0HRU075, 0HRU076, 0HRU077, 0HRU078, 0HRU079, 0HRV07Z, 0HRV075, 0HRV076, 0HRV077, 0HRV078, 0HRV079, 0HBT0ZZ, 0HBT3ZZ, 0HBU0ZZ, 0HBU3ZZ, 0HBV0ZZ, 0HBV3ZZ, 0H2TXYZ, 0H2UXYZ

Procedural Codes: 19328, 19330, 19340, 19342, 19380, 19396, L8600
References
  1. FDA – Executive Summary: Update on the Safety of Silicone Gel-Filled Breast Implants. Food and Drug Administration – Center for Devices and Radiologic Health (2011 June 22). Available at http://www.fda.gov (accessed – 2013 August 30).
  2. FDA – Medical Devices: Silicone Gel-Filled Breast Implants. Food and Drug Administration – Center for Devices and Radiologic Health (2013 August 29). Available at http://www.fda.gov (accessed – 2013 August 30).
  3. FDA – Medical Devices: Saline-Filled Breast Implants. Food and Drug Administration – Center for Devices and Radiologic Health (2013 August 15). Available at http://www.fda.gov (accessed – 2013 August 30).
  4. FDA – Medical Devices: Breast Implant Complications Booklet. Food and Drug Administration – Center for Devices and Radiologic Health (2013 August 29). Available at http://www.fda.gov (accessed – 2013 August 30).
  5. FDA – FDA News Release: FDA Review Indicates Possible Association Between Breast Implants and a Rare Cancer. Food and Drug Administration – Center for Devices and Radiologic Health (2011 June 26). Available at http://www.fda.gov (accessed – 2013 August 30).
  6. FDA – FDA Medical Device Safety Communication: Reports of Anaplastic Large Cell Lymphoma (ALCL) in Women with Breast Implants. Food and Drug Administration – Center for Devices and Radiologic Health (2011 January 26). Available at http://www.fda.gov (accessed – 2013 August 30).
  7. FDA – Preliminary FDA Findings and Analyses: Anaplastic Large Cell Lymphoma (ALCL) In Women with Breast Implants. Food and Drug Administration – Center for Devices and Radiologic Health (2011 January). Available at http://www.fda.gov (accessed – 2013 August 30).
  8. FDA – Medical Devices: Labeling for Approved Breasts Implants. Food and Drug Administration – Center for Devices and Radiologic Health (2013 August 19). Available at http://www.fda.gov (accessed – 2013 August 30).
  9. Gabriel SE, Woods JE, O'Fallon WM et al. Complications leading to surgery after breast implantation. The New England journal of medicine 1997; 336(10):677-82.
  10. Chung KC, Wilkins EG, Beil RJ, Jr. et al. Diagnosis of silicone gel breast implant rupture by ultrasonography. Plast Reconstr Surg 1996; 97(1):104-9.
  11. Netscher DT, Weizer G, Malone RS et al. Diagnostic value of clinical examination and various imaging techniques for breast implant rupture as determined in 81 patients having implant removal. South Med J 1996; 89(4):397-404.
  12. Samuels JB, Rohrich RJ, Weatherall PT et al. Radiographic diagnosis of breast implant rupture: current status and comparison of techniques. Plast Reconstr Surg 1995; 96(4):865-77.
  13. Baker JL. Augmentation mammoplasty. In: Owsley JQ, Jr., Peterson RA, eds. Symposium on aesthetic surgery of the breast. St. Louis: CV Mosby; 1978.
  14. American Society of Plastic and Reconstructive Surgeons. American Society of Plastic and Reconstructive Surgeons Citizens' Petition to the Food and Drug Administration which requests that silicone gel-filled implants remain available because the device is necessary for the public health. Arlington Heights, IL November 29 1991.
  15. Gabriel SE, O'Fallon WM, Kurland LT et al. Risk of connective-tissue diseases and other disorders after breast implantation. N Engl J Med 1994; 330(24):1697-702.
  16. Hennekens CH, Lee IM, Cook NR et al. Self-reported breast implants and connective-tissue diseases in female health professionals. A retrospective cohort study. JAMA 1996; 275(8):616-21.
  17. Sanchez-Guerrero J, Colditz GA, Karlson EW et al. Silicone breast implants and the risk of connective-tissue diseases and symptoms. N Engl J Med 1995; 332(25):1666-70.
  18. Silverman BG, Brown SL, Bright RA et al. Reported complications of silicone gel breast implants: an epidemiologic review. Ann Intern Med 1996; 124(8):744-56.
  19. ECRI Institute. Cancer risk and silicone breast implants. Plymouth Meeting (PA): ECRI Institute; 2012 Jan. 10 p. (Hotline Response).
  20. NIH – Silicone Breast Implants and Breast Cancer Risk. National Cancer Institute at the National Institutes of Health (2010 September 28). Available at http://www.cancer.gov (accessed – 2013 August 30).
  21. NIH – National Cancer Institute Breast Implant Study: Fact Sheet. National Cancer Institute at the National Institutes of Health (2010 September 28). Available at http://www.cancer.gov (accessed – 2013 August 30).
  22. ECRI Institute. Noncancerous risks and adverse outcomes associated with using silicone breast implants. Plymouth Meeting (PA): ECRI Institute; 2012 Mar. 11 p. (Hotline Response).
  23. Reconstructive Breast Surgery/Management of Breast Implants (Archived). Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2012 February) Surgery: 7.01.22.
History
June 2013 New 2013 BCBSMT medical policy.  Previously part of the "Reconstructive Breast Surgery/Management of Breast Implants" policy.
April 2014 Document updated with literature review. The following additions AND changes were made to the post reconstruction and post cosmetic grid: 1) Documented surgical treatment of breast cancer whether a silicone gel-filled or saline-filled implant(s) – covered as a mandated benefit for post reconstruction and cosmetic exclusion for post cosmetic services; 2) Imaging evidence of extrusion of silicone gel-filled or saline-filled implant(s) – covered as a mandated benefit for post reconstruction and cosmetic exclusion for post cosmetic services; 3) Baker Class I augmented breast feels as soft as a normal breast whether a silicone gel-filled or saline-filled implant – not medically necessary for post reconstruction and cosmetic exclusion for post cosmetic services; 4) Chronic breast pain related ONLY to recurrent breast infection, contracture from, or rupture of a silicone gel-filled or  saline-filled implant – not medically necessary for post reconstruction and cosmetic exclusion for post cosmetic services; 5) Patient anxiety or fear of cancer risk, including but not limited to anaplastic large cell lymphoma (ALCL), associated with components of implant envelope (sleeve or covering) or contents of the implant whether silicone gel-filled or saline-filled implant – not medically necessary for post reconstruction and cosmetic exclusion for post cosmetic services;  6) Breast or chest wall pain unrelated to contractures or rupture – not medically necessary for post reconstruction and cosmetic exclusion for post cosmetic services;  and, 7) Patient anxiety or fear of potential systemic conditions from silicone gel-filled or saline-filled implant – not medically necessary for post reconstruction and cosmetic exclusion for post cosmetic services. Description and Rationale significantly revised.
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Breast Implant, Removal and/or Insertion