TL;DR: Aetna, a CVS Health company, modified CPB 0142 covering breast implant removal, effective March 20, 2026. Here's what changes for billing teams.
This update to the Aetna breast implant removal coverage policy reshapes medical necessity criteria across CPT codes 19328, 19330, 19370, and 19371 — among others. If your practice bills for breast implant procedures, you need to review these criteria before submitting claims against this policy. The stakes are high: this policy draws a sharp line between covered removals and cosmetic exclusions, and the wrong documentation sinks the claim.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Aetna, a CVS Health company |
| Policy | Breast Implant Removal |
| Policy Code | CPB 0142 |
| Change Type | Modified |
| Effective Date | March 20, 2026 |
| Impact Level | High |
| Specialties Affected | Plastic surgery, general surgery, breast surgery, oncology, reconstructive surgery |
| Key Action | Audit documentation for contracture classification, rupture type, and implant history before billing CPT 19328, 19330, 19370, or 19371 |
Aetna Breast Implant Removal Coverage Criteria and Medical Necessity Requirements 2026
The Aetna breast implant removal coverage policy under CPB 0142 Aetna system creates two distinct coverage tiers. Your eligibility for reimbursement depends on which tier your patient falls into — and the distinction matters a lot.
Tier 1: All covered implant origins. Aetna covers removal with capsulectomy or capsulotomy (CPT 19371 or 19370) for members who received implants through cosmetic augmentation, post-mastectomy reconstruction, or gender dysphoria treatment. Ten qualifying indications apply to this group.
Those ten indications are:
| # | Covered Indication |
|---|---|
| 1 | Breast cancer in the implanted breast or contralateral breast, where removal is necessary to excise the cancer |
| 2 | Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) |
| 3 | Extrusion of the implant through skin |
| 4 | Recurrent infections |
| 5 | Baker Class IV contracture with severe pain |
| 6 | Severe contracture that interferes with mammography |
| 7 | Intra- or extra-capsular rupture of silicone gel-filled implants |
| 8 | Cutaneous hypersensitivity-like reactions after failed conventional treatments (antibiotics, oral corticosteroids, topical corticosteroids) |
| 9 | Textured implants withdrawn from the market at FDA request — specifically Allergan Biocell |
| 10 | Textured implants with persistent post-healing symptoms: pain, lumps, swelling, or asymmetry |
Tier 2: Reconstruction and gender dysphoria cases only. Members whose implants came from a medically necessary mastectomy — cancer or prophylactic — or gender dysphoria treatment qualify for two additional covered indications not available to cosmetic augmentation patients:
| # | Covered Indication |
|---|---|
| 1 | Baker Class III contracture |
| 2 | Extra-capsular rupture of a saline implant if it compromises cosmetic outcome |
The practical takeaway: a cosmetic augmentation patient with Baker Class III contracture is not covered. A reconstruction patient with the same finding is. Your intake and prior authorization documentation must clearly establish the original implant indication.
Bilateral rule. If only one breast meets a covered removal criterion, Aetna considers removal of both implants — plus capsulectomy or capsulotomy on the unaffected side — medically necessary when both are removed at the same time. Bill accordingly for both sides.
En bloc capsulectomy (CPT 19371 with a margin of uninvolved tissue) is a separate matter. Aetna covers it only for capsular malignancy. Requests for en bloc for other indications — including patient preference or "preventive" reasoning — will be denied. Document the malignancy clearly.
Implant insertion and replacement following a medically necessary mastectomy is covered under CPT 19340 and 19342. This also applies to patients with Poland's syndrome who meet criteria under CPB 0272. For reconstruction patients, the policy covers initial insertion and replacement — not just removal.
Aetna Breast Implant Removal Exclusions and Non-Covered Indications
Several removal scenarios are explicitly excluded from coverage under CPB 0142. Know these before you submit.
Ruptured saline implants in cosmetic augmentation patients. Removal of ruptured saline-filled implants is not medically necessary when the original implants were placed for cosmetic augmentation. This is one of the sharpest distinctions in the policy. Saline rupture in a reconstruction patient with cosmetic outcome compromise is covered. The same rupture in a cosmetic augmentation patient is not.
Silicone implant removal for autoimmune disease. Aetna does not consider removal medically necessary for autoimmune disease indications. IgG testing in connection with silicone implants is also not covered — the policy notes that IgG antibody development is neither specific to silicone implants nor indicative of autoimmune disease causation.
Fat grafting for breast reconstruction. CPT codes 15769, 15771, +15772, 15773, and +15774 — autologous fat grafting procedures — are not covered under the indications listed in this CPB. If your surgeons routinely combine fat grafting with implant removal or reconstruction, do not expect coverage for those components under CPB 0142.
These exclusions are firm. Appealing them without new clinical evidence is a low-probability strategy. If you're seeing claim denials on these codes, review whether the documentation genuinely meets a covered indication before investing in an appeal.
Coverage Indications at a Glance
| Indication | Eligible Implant Origin | Status | Relevant Codes | Notes |
|---|---|---|---|---|
| Breast cancer requiring implant removal for excision | All covered origins | Covered | 19328, 19330, 19371 | Documentation of surgical necessity required |
| BIA-ALCL | All covered origins | Covered | 19328, 19330, 19371 | Textured implant history critical |
| Implant extrusion through skin | All covered origins | Covered | 19328, 19330 | |
| Recurrent infections | All covered origins | Covered | 19328, 19330, 19370, 19371 | |
| Baker Class IV contracture with severe pain | All covered origins | Covered | 19370, 19371 | Photographic documentation may be required |
| Severe contracture interfering with mammography | All covered origins | Covered | 19370, 19371 | Photographic documentation may be required |
| Silicone implant rupture (intra- or extra-capsular) | All covered origins | Covered | 19328, 19330, 19371 | Both rupture types covered for silicone |
| Cutaneous hypersensitivity after failed treatment | All covered origins | Covered | 19328, 19330 | Must document failed antibiotics, oral and topical corticosteroids |
| Allergan Biocell textured implants (FDA-recalled) | All covered origins | Covered | 19328, 19330, 19371 | FDA recall documentation supports claim |
| Textured implants with persistent post-healing symptoms | All covered origins | Covered | 19328, 19330 | Symptoms must occur after incision fully healed |
| Baker Class III contracture | Reconstruction / gender dysphoria only | Covered | 19370, 19371 | NOT covered for cosmetic augmentation patients |
| Saline rupture compromising cosmetic outcome | Reconstruction / gender dysphoria only | Covered | 19328, 19330 | NOT covered for cosmetic augmentation patients |
| Ruptured saline implant (cosmetic augmentation) | Cosmetic augmentation | Not Covered | 19328, 19330 | Explicit exclusion |
| En bloc capsulectomy | All | Covered only for capsular malignancy | 19371 | All other indications denied |
| Silicone removal for autoimmune disease | All | Not Covered | 19328, 19330 | IgG testing also excluded |
| Autologous fat grafting | All | Not Covered | 15769, 15771, +15772, 15773, +15774 | Not covered under CPB 0142 indications |
| Implant replacement after medically necessary mastectomy | Reconstruction / gender dysphoria only | Covered | 19340, 19342 | Also applies to Poland's syndrome (see CPB 0272) |
Aetna Breast Implant Removal Billing Guidelines and Action Items 2026
These are the steps your billing team should take before and after the March 20, 2026 effective date.
| # | Action Item |
|---|---|
| 1 | Audit your prior authorization workflow for CPT 19328, 19330, 19370, and 19371 now. Check that your PA intake process captures the original implant indication — cosmetic, reconstructive, or gender dysphoria. This is the single most important data point for determining which coverage tier applies. |
| 2 | Update documentation requirements for Baker Class contracture cases. The policy specifies that photographic documentation of contracture may be required. Make this a standing requirement in your chart prep process. Missing photos on a Class III or Class IV contracture claim is an easy denial that's hard to overturn after the fact. |
| 3 | Flag all Allergan Biocell cases in your scheduling system. FDA recall documentation is your primary support for these claims. If a patient has Allergan Biocell textured implants, attach recall documentation to the claim file before submission. |
| 4 | Remove fat grafting CPT codes (15769, 15771, +15772, 15773, +15774) from breast implant removal charge capture bundles. These are not covered under CPB 0142. If your surgeons perform fat grafting at the same encounter, you need separate clinical justification and a different billing pathway — or a patient financial responsibility conversation before surgery. |
| 5 | Verify bilateral removal billing. When both implants are removed at the same encounter and only one side meets the covered criterion, bill capsulectomy or capsulotomy for the contralateral breast as medically necessary under the bilateral rule. Many teams miss this. Document that both removals occurred at the same operative session. |
| 6 | Do not bill en bloc capsulectomy (CPT 19371) without a confirmed capsular malignancy diagnosis. Patient preference, surgeon preference, or "precautionary" justifications will not pass Aetna's medical necessity review under this policy. If you're seeing denials on 19371, check whether the malignancy diagnosis is clearly documented and coded. |
| 7 | For cutaneous hypersensitivity cases, document treatment failure before seeking prior auth. The policy requires failed conventional treatments: antibiotics, oral corticosteroids, and topical corticosteroids. If your records don't show all three were tried and failed, Aetna will deny the prior authorization request for removal. |
If your practice handles a high volume of mixed cosmetic and reconstruction patients, talk to your compliance officer before the March 20 effective date. The tier distinction creates real claim denial risk if your intake process doesn't reliably capture original implant indication at scheduling.
| 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 | Type | Description |
|---|---|---|
| 19325 | CPT | Mammaplasty, augmentation with prosthetic implant |
| 19328 | CPT | Removal of intact mammary implant |
| 19330 | CPT | Removal of mammary implant material |
| 19340 | CPT | Immediate insertion of breast prosthesis following mastopexy, mastectomy, or in reconstruction |
| 19342 | CPT | Delayed insertion of breast prosthesis following mastopexy, mastectomy, or in reconstruction |
| 19370 | CPT | Open periprosthetic capsulotomy, breast |
| 19371 | CPT | Periprosthetic capsulectomy, breast |
Not Covered CPT Codes (Under CPB 0142 Indications)
| Code | Type | Description | Reason |
|---|---|---|---|
| 15769 | CPT | Grafting of autologous soft tissue, other, harvested by direct excision (e.g., fat, dermis, fascia) | Not covered for indications listed in CPB 0142 |
| 15771 | CPT | Grafting of autologous fat harvested by liposuction to trunk, breasts, scalp, arms, and/or legs | Not covered for indications listed in CPB 0142 |
| +15772 | CPT | Each additional 50 cc injectate (add-on to 15771) | Not covered for indications listed in CPB 0142 |
| 15773 | CPT | Grafting of autologous fat harvested by liposuction to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet | Not covered for indications listed in CPB 0142 |
| +15774 | CPT | Each additional 25 cc injectate (add-on to 15773) | Not covered for indications listed in CPB 0142 |
HCPCS Codes
| Code | Type | Description |
|---|---|---|
| L8020 | HCPCS | Breast prosthesis, mastectomy bra |
| L8021 | HCPCS | Breast prosthesis, mastectomy bra with integrated breast prosthesis |
| L8022 | HCPCS | Breast prosthesis, mastectomy bra, updated |
ICD-10-CM Codes
The CPB 0142 policy data does not include a specific list of covered ICD-10-CM diagnosis codes. Map to the clinical indications outlined in the medical necessity criteria — BIA-ALCL, capsular contracture grade, implant rupture type, and infection — and document diagnosis codes accordingly. Consult your coding team to confirm ICD-10 alignment with each covered indication before submitting claims.
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