Aetna modified CPB 0142 governing breast implant removal coverage, effective September 26, 2025. Here's what billing teams need to do.
Aetna, a CVS Health company, updated its breast implant removal coverage policy under CPB 0142 Aetna system, affecting CPT codes 19328, 19330, 19370, and 19371 among others. The policy draws a sharp line between patients with cosmetic augmentation history and those with post-mastectomy reconstruction — and that line determines which indications qualify for coverage. If your practice bills for breast implant removal, you need to know exactly where your patients fall before submitting a claim.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna |
| Policy | Breast Implant Removal — CPB 0142 |
| Policy Code | CPB 0142 |
| Change Type | Modified |
| Effective Date | September 26, 2025 |
| Impact Level | High |
| Specialties Affected | Plastic surgery, general surgery, breast surgery, oncology, reconstructive surgery |
| Key Action | Audit all pending and upcoming breast implant removal authorizations against the two-tier criteria structure before billing CPT 19328, 19330, 19370, or 19371 |
Aetna Breast Implant Removal Coverage Criteria and Medical Necessity Requirements 2025
The Aetna breast implant removal coverage policy operates on a two-tier structure. Tier one covers a broader group — any member who received implants via cosmetic augmentation, post-mastectomy reconstruction, or augmentation for gender dysphoria. Tier two adds extra indications, but only for members whose implants followed a medically necessary mastectomy (cancer or prophylactic) or augmentation for gender dysphoria.
The real issue here is that many practices treat all implant removal requests as equivalent. They're not. The patient's original indication for the implant changes what Aetna will cover today.
Tier One: All Implant Patients
For any member regardless of why they originally received implants, Aetna considers removal and capsulectomy or capsulotomy (CPT 19371 and 19370) medically necessary for these indications:
| # | Covered Indication |
|---|---|
| 1 | Breast cancer in the implanted breast or contralateral breast, where removal is needed to excise the cancer |
| 2 | Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) |
| 3 | Extrusion of implant through skin |
| 4 | Recurrent infections involving the implant |
| 5 | Baker Class IV contracture with severe pain |
| 6 | Severe contracture interfering with mammography |
| 7 | Intra- or extra-capsular rupture of a silicone gel-filled implant |
| 8 | Cutaneous hypersensitivity-like reactions that have failed conventional treatments (antibiotics, oral corticosteroids, topical corticosteroids) |
| 9 | Allergan Biocell textured implants withdrawn from the market at FDA's request |
| 10 | Textured implants with persistent symptoms — pain, lumps, swelling, or asymmetry — after the surgical incision has fully healed |
That last two points reflect FDA's 2019 Allergan Biocell recall. If your practice still sees patients with these implants who haven't yet had them removed, coverage is available under this tier.
Tier Two: Post-Mastectomy and Gender Dysphoria Patients Only
Members whose implants followed a medically necessary mastectomy or augmentation for gender dysphoria qualify for two additional indications that cosmetic augmentation patients do not:
| # | Covered Indication |
|---|---|
| 1 | Baker Class III contracture |
| 2 | Extra-capsular rupture of a saline implant, if the rupture compromises the cosmetic outcome |
This distinction matters enormously for prior authorization. A cosmetic augmentation patient with Baker Class III contracture does not meet medical necessity under this policy. A post-mastectomy reconstruction patient with the same finding does. Document the original surgical indication clearly in every auth request.
The Bilateral Rule
Aetna covers simultaneous removal of both implants when only one meets criteria — as long as both are removed at the same time. If you bill 19328 or 19330 for the second breast in a staged procedure, you're outside this rule. Both must come out in the same surgical session.
Replacement Implants
Aetna considers replacement implants medically necessary for post-mastectomy reconstruction patients, gender dysphoria augmentation patients, and women with Poland's syndrome meeting CPB 0272 criteria. Bill CPT 19340 for immediate insertion or 19342 for delayed insertion. Replacement is not covered for cosmetic augmentation patients as a standalone benefit under this policy.
En Bloc Capsulectomy
This is a key restriction. En bloc capsulectomy — removal of the implant and capsule with a margin of uninvolved tissue — is medically necessary only for capsular malignancy. Full stop. Practices performing en bloc for contracture, rupture, or patient preference on cosmetic augmentation patients should expect claim denial under CPB 0142. This is not a gray area.
Aetna Breast Implant Removal Exclusions and Non-Covered Indications
Two specific procedures carry explicit non-covered status under this coverage policy.
Ruptured saline implants in cosmetic augmentation patients. Aetna does not consider removal of ruptured saline-filled implants medically necessary when the member originally had cosmetic breast augmentation. Silicone rupture is covered. Saline rupture in this population is not. That's a meaningful clinical distinction with real reimbursement consequences.
Autologous fat grafting. CPT codes 15769, 15771, +15772, 15773, and +15774 — covering autologous fat harvesting and grafting by direct excision or liposuction — are not covered for indications listed in CPB 0142. If your surgeon plans fat grafting as part of an implant removal and reconstruction case, do not expect Aetna coverage for those codes. Bill them separately and counsel patients on out-of-pocket exposure before the procedure.
Coverage Indications at a Glance
| Indication | Patient Population | Coverage Status | Key Codes | Notes |
|---|---|---|---|---|
| Breast cancer requiring implant removal | All implant patients | Covered | 19328, 19330, 19371 | Must be necessary to excise cancer |
| BIA-ALCL | All implant patients | Covered | 19328, 19330, 19371 | — |
| Implant extrusion through skin | All implant patients | Covered | 19328, 19330, 19371 | — |
| Recurrent infections | All implant patients | Covered | 19328, 19330, 19371 | — |
| Baker Class IV contracture with severe pain | All implant patients | Covered | 19370, 19371 | Photo documentation may be required |
| Severe contracture interfering with mammography | All implant patients | Covered | 19370, 19371 | Photo documentation may be required |
| Silicone gel implant rupture (intra- or extra-capsular) | All implant patients | Covered | 19328, 19330, 19371 | — |
| Cutaneous hypersensitivity failed conventional treatment | All implant patients | Covered | 19328, 19330, 19371 | Must document failed antibiotics, oral/topical corticosteroids |
| Allergan Biocell textured implants (FDA recall) | All implant patients | Covered | 19328, 19330, 19371 | — |
| Textured implant persistent symptoms post-healing | All implant patients | Covered | 19328, 19330, 19371 | Symptoms: pain, lumps, swelling, asymmetry |
| Baker Class III contracture | Post-mastectomy / gender dysphoria only | Covered | 19370, 19371 | NOT covered for cosmetic augmentation patients |
| Saline implant extra-capsular rupture (cosmetic outcome) | Post-mastectomy / gender dysphoria only | Covered | 19328, 19330 | NOT covered for cosmetic augmentation patients |
| Contralateral removal (simultaneous, one breast meets criteria) | All implant patients | Covered | 19328, 19330, 19371 | Same surgical session required |
| Replacement implants | Post-mastectomy / gender dysphoria / Poland's syndrome | Covered | 19340, 19342 | Per CPB 0272 for Poland's syndrome |
| En bloc capsulectomy | All patients | Covered for capsular malignancy only | 19371 | Not covered for contracture or rupture |
| Saline implant rupture | Cosmetic augmentation patients | Not Covered | 19328, 19330 | Saline-specific exclusion |
| Autologous fat grafting | All patients | Not Covered | 15769, 15771, +15772, 15773, +15774 | No indications under CPB 0142 |
Aetna Breast Implant Removal Billing Guidelines and Action Items 2025
| # | Action Item |
|---|---|
| 1 | Audit your auth requests before September 26, 2025. Any prior authorization submitted after the effective date must reflect the two-tier criteria. Check every pending request. Is the patient cosmetic augmentation, post-mastectomy, or gender dysphoria? That answer changes what indications you can support. |
| 2 | Document the original implant indication in every record. Operative reports, prior auth requests, and clinical notes should all state clearly why the patient received their original implants. Aetna will use this to determine which tier applies. Missing documentation is a fast path to claim denial. |
| 3 | Pull photo documentation for all contracture claims. The policy specifically states that photographic documentation of contracture may be required. Don't wait for Aetna to request it. Send it with the auth package for Baker Class III and Class IV claims. This applies to CPT 19370 and 19371 when contracture is the indication. |
| 4 | Flag autologous fat grafting codes before any combined case goes to billing. CPT 15769, 15771, +15772, 15773, and +15774 are explicitly non-covered under CPB 0142. If a surgeon plans fat grafting alongside implant removal, your billing team needs to know before the case — not after. Patients need financial counseling on these codes ahead of surgery. |
| 5 | Confirm bilateral billing is same-session only. If the plan is to remove the second implant in a separate surgery, it needs its own qualifying indication. You cannot use the bilateral rule across two surgical dates. Bill CPT 19328 or 19330 accordingly, and make sure your operative notes document the bilateral removal in a single session. |
| 6 | Verify en bloc capsulectomy documentation shows capsular malignancy. En bloc coverage is limited. If your surgeon performs en bloc and the pathology report isn't documenting malignancy, expect a denial. Review surgical plans with your clinical team before submitting these claims. |
| 7 | Check implant device records for Allergan Biocell. Patients who still have recalled Allergan Biocell textured implants in place qualify for removal under tier one. If your practice treats patients from the recall era who haven't acted yet, proactive outreach and documentation of the device makes auth straightforward. Pull implant device logs now. |
If you're uncertain how this two-tier structure applies to a complex patient mix, loop in your compliance officer before the September 26, 2025 effective date. Especially if your practice handles high volumes of cosmetic augmentation patients — the saline rupture exclusion alone could affect a significant number of cases.
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Breast Implant Removal Under CPB 0142
Covered CPT Codes (When Selection Criteria Are Met)
| Code | Description |
|---|---|
| 19325 | Mammoplasty, augmentation with prosthetic implant |
| 19328 | Removal of intact mammary implant |
| 19330 | Removal of mammary implant material |
| 19340 | Immediate insertion of breast prosthesis following mastopexy, mastectomy, or in reconstruction |
| 19342 | Delayed insertion of breast prosthesis following mastopexy, mastectomy, or in reconstruction |
| 19370 | Open periprosthetic capsulotomy, breast |
| 19371 | Periprosthetic capsulectomy, breast |
Not Covered CPT Codes
| Code | Description | Reason |
|---|---|---|
| 15769 | Grafting of autologous soft tissue, other, harvested by direct excision (e.g., fat, dermis, fascia) | Not covered for indications listed in CPB 0142 |
| 15771 | Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs | Not covered for indications listed in CPB 0142 |
| +15772 | Each additional 50 cc injectate, or part thereof (add-on to primary procedure) | Not covered for indications listed in CPB 0142 |
| 15773 | Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet | Not covered for indications listed in CPB 0142 |
| +15774 | Each additional 25 cc injectate, or part thereof (add-on to primary procedure) | Not covered for indications listed in CPB 0142 |
HCPCS Codes
| Code | Description |
|---|---|
| L8020 | Breast prosthesis (external) |
| L8021 | Breast prosthesis (external) |
| L8022 | Breast prosthesis (external) |
Note: The policy data does not include specific ICD-10-CM codes for CPB 0142. Use clinically appropriate ICD-10-CM codes aligned to the documented indication (e.g., BIA-ALCL, capsular contracture, implant rupture) and confirm with your coding team.
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