Coverage eligibility of breast implants for the purposes of augmentation may depend on contract language. After reconstructive breast surgery on one side, insertion of an implant on the contralateral, normal side is rarely necessary to achieve symmetry.
Reconstructive breast surgery may be considered medically necessary after a medically necessary mastectomy, accidental injury, or trauma. Medically necessary mastectomies are most typically done as treatment for cancer. Reconstruction may be performed by an implant-based approach or through the use of autologous tissue.
Explantation of a silicone gel-filled breast implant may be considered medically necessary in all cases for a documented implant rupture, infection, extrusion, Baker class IV contracture, or surgical treatment of breast cancer.
Explantation of a ruptured saline-filled breast implant may be considered medically necessary only in those individuals who had originally undergone breast implantation for reconstructive purposes. Otherwise, indications for the explantation of a saline-filled implant are similar to those of a silicone-filled implant.
Explantation of a breast implant associated with a Baker class III contracture may be considered medically necessary only in those individuals who had originally undergone breast implantation for reconstructive purposes.
Reconstructive breast surgery after explantation of an implant is considered medically necessary only in those individuals who had originally undergone breast implantation for reconstructive purposes.
The following indications for explantation of implants are considered investigational:
Systemic symptoms, attributed to connective tissue diseases, autoimmune diseases;
Anxiety;
Baker class III contractures in individuals with implants for cosmetic purposes;
Rupture of a saline implant in individuals with implants for cosmetic purposes;
Pain not related to contractures;
Preventive explantation in asymptomatic individuals to reduce remote risk of anaplastic large cell lymphoma;
Preventive explantation in asymptomatic individuals to reduce remote risk of B cell lymphoma.
