TRANSMITTAL #: 124

DATE: 06/30/2010

TRICARE CHANGE #: NA

 

CHAMPVA POLICY MANUAL

 

CHAPTER: 2

SECTION: 2.6

TITLE:  SILICONE OR SALINE BREAST IMPLANT REMOVAL

 

AUTHORITY:  38 CFR 17.270(a) and 17.272(a)

 

RELATED AUTHORITY:  32 CFR 199.4(a)(1), (b)(2)(vii), (e)(8)(iv), and (e)(9)

 

 

I. EFFECTIVE DATE(S)

June 30, 1993

II. PROCEDURE CODE(S)

CPT Codes: 19328, 19330, 77058, and 77059

III. DESCRIPTION(S)

A. The removal of silicone or saline mammary implant material.

IV. POLICY

A. Removal of silicone or saline breast implants is covered when one of the following is documented or medical review has confirmed the medical necessity:

1. The initial silicone or saline breast implantation was or would have been a covered benefit (see Chapter 2, Section 2.2, Breast Construction as a Result of a Congenital Anomaly) and the removal of silicone or saline breast implants are considered medically necessary.  Medical documentation of signs or symptoms of complications may include, but are not limited to:

a. Signs and symptoms that may signal implant rupture (leakage or deflation) of the silicone or saline materials.

b. Capsular formation and contracture, that is, the tissue around a breast implant hardens, which can cause pain, and sometimes a need for further surgery, these indications may be manifested by changes in firmness, size, shape, or color of the implanted breast.

c. Infection and/or cellulitis.

2. Breast MRI (Magnetic Resonance Imaging) to detect implant rupture is covered provided the initial implantation was or would have been covered by CHAMPVA.

3. If the initial silicone or saline breast implant surgery was not originally covered, the implant removal is covered only when medically necessary to treat a complication in another body part that is a separate medical condition and is unresponsive to medical management, such as systemic sepsis.

V. EXCLUSION(S)

A. Removal of silicone or saline breast implants for the presence of autoimmune or connective tissue disorders.

B. In the case of implants not originally covered or coverable by CHAMPVA, any implant damage, hardening, or leakage, does not qualify as a separate medical condition.  They are considered unfortunate sequelae resulting from the initial non-covered surgery.

*END OF POLICY*