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TRICARE Policy Manual 6010.63-M, April 2021
Surgery
Chapter 4
Section 5.5
Silicone Or Saline Breast Implant Removal
Issue Date:  June 30, 1993
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  
1.0  CPT CODES
19328, 19330
2.0  DESCRIPTION
The removal of silicone or saline mammary implant material.
3.0  POLICY
3.1  Removal of silicone or saline breast implants is covered if the initial silicone or saline breast implantation was or would have been a covered benefit.
3.2  Signs or symptoms of complications must be present and documented. Current medical literature supports removal of silicone or saline breast implants for the following indications:
•  Signs and symptoms that may signal implant rupture; and
•  Capsular contracture.
3.3  If the initial silicone or saline breast implant surgery was for an indication not covered or coverable by TRICARE, implant removal may be covered only if it is necessary treatment of a complication which represents a separate medical condition. See Section 1.1.
3.4  Breast Magnetic Resonance Imaging (MRI) to detect implant rupture is covered if the implantation procedure was, or would have been covered by TRICARE (e.g., was related to a covered mastectomy and reconstruction and not a solely cosmetic procedure).
4.0  EXCLUSIONS
4.1  Removal of silicone or saline breast implants for the presence of autoimmune or connective tissue disorders.
4.2  In the case of implants not originally covered or coverable, implant damage, hardening, leakage, and autoimmune disorder do not qualify as separate medical conditions. They are considered unfortunate sequelae resulting from the initial non-covered surgery, and, therefore, are excluded.
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