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 PROCEDURE
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. The implantation
of the breast implants must have been covered by TRICARE.
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.
- END -