CIGNA Breast Implant Removal Coverage Policy MM 0048 Updated for 2026

Cigna has modified Medical Coverage Policy MM 0048, which governs coverage criteria for breast implant removal and replacement procedures. Effective March 12, 2026, this update affects how billing teams should approach prior authorization, medical necessity documentation, and code selection for patients presenting with implant-related complications or elective removal requests. If your practice performs breast implant removal—or bills for capsulectomy, implant revision, or replacement procedures—this policy change deserves immediate attention.

What Cigna's MM 0048 Policy Covers — and What It Doesn't

Cigna's MM 0048 policy addresses the removal of both silicone gel-filled and saline-filled breast implants, as well as the subsequent surgical implantation of a new FDA-approved breast implant. The policy applies across a range of clinical scenarios: implant rupture, capsular contracture, peri-implant capsule revision, and replacement procedures performed on a separate day from mastectomy.

One critical boundary billing teams must understand: MM 0048 does not govern reconstructive breast surgery following mastectomy or lumpectomy. Those procedures fall under Medical Coverage Policy 0178 (Breast Reconstruction Following Mastectomy or Lumpectomy). Submitting reconstruction-related claims under MM 0048 creates a mismatch that can generate denials or delays, so proper policy routing matters from the moment a case is scheduled.

The distinction between "removal only" and "removal with replacement" scenarios also has coding implications that map directly to medical necessity criteria—which are now updated under this March 2026 revision.

Affected Codes — Cigna MM 0048 Breast Implant Removal

Covered Codes (Medically Necessary When Criteria Are Met)

These CPT codes are covered under Cigna MM 0048 when the applicable medical necessity criteria are satisfied. Claims submitted without adequate documentation supporting those criteria are at high risk for denial.

Note that CPT 19330 specifically captures ruptured implant removal inclusive of implant contents—both saline and silicone gel scenarios are bundled under this code. Billing CPT 19328 for a ruptured implant would represent an incorrect code assignment and is likely to trigger clinical review or denial.

Not Covered / Cosmetic Designation

Mastopexy (CPT 19316) carries a default cosmetic designation under this policy. If a clinical argument exists for medical necessity in a specific case—for example, mastopexy performed in the context of implant removal with significant ptosis—your documentation needs to be unusually strong, and prior authorization should be secured before the procedure is performed. Without it, expect denial and a difficult appeals path.

Related ICD-10 Diagnosis Codes

The policy data for MM 0048 does not list specific ICD-10-CM codes in this update. However, billing teams should ensure diagnosis codes accurately reflect the clinical indication—such as implant rupture, capsular contracture, or implant-related pain—to support medical necessity at claim review.

Cigna's Medical Necessity Framework for Implant Removal Procedures

Cigna, one of the largest commercial payers in the U.S., applies a criteria-based medical necessity standard to each of the covered CPT codes under MM 0048. Coverage is not automatic for any of them—each claim must satisfy the "applicable criteria" referenced in the policy's coverage position.

For rupture cases (CPT 19330), clinical imaging or intraoperative findings typically drive medical necessity. For capsule-related procedures (CPT 19370 and 19371), the documented severity of capsular contracture—often graded using the Baker Classification—is central to justifying intervention. Grade III or IV contracture with documented pain or functional limitation generally meets the threshold; Grade I or II typically does not.

For replacement procedures (CPT 19342), timing is significant. This code applies specifically when implant insertion occurs on a separate day from mastectomy. If insertion happens at the same surgical session as mastectomy, MM 0048 is the wrong policy—refer back to Policy 0178 for that scenario.

Prior authorization requirements are not explicitly detailed in the summary data for this update, but given the complexity and cost of these procedures, Cigna historically requires prior authorization for most surgical breast procedures. Treat prior auth as assumed required until your provider relations or portal verification confirms otherwise.

What Your Billing Team Should Do