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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.
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