Aetna · Clinical coverage policy

Aetna Breast Reconstructive Surgery coverage criteria

Aetna CPB 0185 covers breast reconstruction (including flap procedures, implants/tissue expanders, autologous fat grafting, nipple/areolar reconstruction and tattooing, listed acellular dermal matrices, and symmetry procedures on the unaffected breast) when it follows a medically necessary mastectomy or lumpectomy that causes significant deformity — done for breast cancer treatment/prophylaxis or for severe fibrocystic disease unresponsive to therapy — or to correct asymmetry from Poland syndrome or trauma. Several newer techniques and matrices (e.g., SimpliDerm, nerve coaptation, intraoperative hypothermia, 3D volumetric imaging, venous super-charging) are experimental/investigational, and reconstructive surgery for any indication not listed is considered cosmetic and not covered. The bulletin does not address precertification.

Policy CPB 0185 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0185

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0185 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Breast Reconstructive Surgery (CPT 19316), and what gets it denied?

Path
Aetna CPB 0185 covers breast reconstruction (including flap procedures, implants/tissue expanders, autologous fat grafting, nipple/areolar reconstruction and tattooing, listed acellular dermal matrices, and symmetry procedures on the unaffected breast) when it follows a medically necessary mastectomy or lumpectomy that causes significant deformity — done for breast cancer treatment/prophylaxis or for severe fibrocystic disease unresponsive to therapy — or to correct asymmetry from Poland syndrome or trauma. Several newer techniques and matrices (e.g., SimpliDerm, nerve coaptation, intraoperative hypothermia, 3D volumetric imaging, venous super-charging) are experimental/investigational, and reconstructive surgery for any indication not listed is considered cosmetic and not covered. The bulletin does not address precertification. Coverage criteria include: Reconstruction after a medically necessary mastectomy or lumpectomy that results in a significant deformity, where the mastectomy/lumpectomy was performed for (ONE of): treatment of or prophylaxis against breast cancer; OR chronic, severe fibrocystic breast disease (cystic mastitis) unresponsive to medical therapy; Autologous fat grafting: harvesting (via lipectomy or liposuction) and grafting of autologous fat as a replacement for implants for breast reconstruction, or to fill defects after breast conservation surgery or other reconstructive techniques; Breast asymmetry correction in Poland Syndrome: surgical correction of chest wall deformity causing functional deficit when criteria in CPB 0272 are met; Post-mastectomy/lumpectomy asymmetry: medically necessary procedures on the non-diseased/unaffected/contralateral breast to produce a symmetrical appearance — may include areolar and nipple reconstruction, areolar and nipple tattooing, augmentation mammoplasty, augmentation with implantation of FDA-approved internal breast prosthesis when the unaffected breast is smaller than the smallest available internal prosthesis, breast implant removal and subsequent re-implantation when performed to produce a symmetrical appearance, breast reduction by mammoplasty or mastopexy, capsulectomy, capsulotomy, and reconstructive surgery revisions; Prompt repair of breast asymmetry due to trauma; Medically necessary procedure: capsulectomy; Medically necessary procedure: capsulotomy; Medically necessary procedure: implantation of FDA-approved internal breast prosthesis; Medically necessary procedure: mastopexy; Medically necessary procedure: insertion of breast prostheses; Medically necessary procedure: tissue expanders; Medically necessary procedure: latissimus dorsi (LD) myocutaneous flap reconstruction; Medically necessary procedure: Rubens flap; Medically necessary procedure: superficial inferior epigastric perforator (SIEP) flap; Medically necessary procedure: superior or inferior gluteal free flap; Medically necessary procedure: transverse upper gracilis (TUG) flap; Medically necessary procedure: transverse rectus abdominis myocutaneous (TRAM) flap; Medically necessary procedure: deep inferior epigastric perforator (DIEP) flap; Medically necessary procedure: superficial inferior epigastric artery (SIEA) flap; Medically necessary procedure: superior gluteal artery perforator (SGAP) flap; Medically necessary procedure: profunda artery perforator flap; Medically necessary procedure: similar procedures, including skin sparing techniques; Medically necessary procedure: autologous fat harvesting and grafting; Medically necessary procedure: associated nipple and areolar reconstructions and tattooing; Medically necessary procedure: reduction (or augmentation in some cases) mammoplasty and related procedures on the unaffected side for symmetry; Medically necessary acellular dermal matrix: Alloderm (LifeCell Corp., Branchburg, NJ); Medically necessary acellular dermal matrix: Alloderm-RTU (LifeCell Corp., Branchburg, NJ); Medically necessary acellular dermal matrix: Cortiva (formerly AlloMax, NeoForm) (Davol, Inc., Warwick, RI); Medically necessary acellular dermal matrix: DermACELL (Novadaq Technologies, Bonita Springs, FL); Medically necessary acellular dermal matrix: DermaMatrix (Musculoskeletal Transplant Foundation/Synthes CMF, West Chester, PA); Medically necessary acellular dermal matrix: FlexHD (Musculoskeletal Transplant Foundation/Ethicon, Inc., Somerville, NJ); Medically necessary acellular dermal matrix: Strattice (LifeCell Corp., Branchburg, NJ); Medically necessary acellular dermal matrix: SurgiMend (TEI Biosciences, Boston, MA). Applies to 22 codes: 19316, 19318, 19325, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 15769, 15771, 15772, 15773, 15774.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
Trap
Policy exclusions and limitations: Experimental, investigational, or unproven (insufficient evidence to support effectiveness of the approach): Artia Reconstructive Tissue Matrix; Experimental, investigational, or unproven: Biodesign Nipple Reconstruction Cylinder; Experimental, investigational, or unproven: body lift perforator flap technique for breast reconstruction; Experimental, investigational, or unproven: intraoperative hypothermia in breast reconstruction; Experimental, investigational, or unproven: nerve coaptation for improvement of sensation following breast reconstruction; Experimental, investigational, or unproven: pre-operative computed tomographic angiography in planning thoraco-dorsal artery perforator flap in breast and soft tissue reconstruction; Experimental, investigational, or unproven: SimpliDerm (human acellular dermal matrix) (Azyi Biologics Inc., Silver Spring, MD) for breast reconstruction surgery; Experimental, investigational, or unproven: three-dimensional (3D) volumetric imaging and reconstruction of breast or axillary lymph node; Experimental, investigational, or unproven: venous super-charging in autologous breast reconstruction with abdominal-based flaps; Cosmetic (not covered): Aetna considers breast reconstructive surgery to be cosmetic for all other indications not listed above. Claims may be denied when the requested service falls under these.

Source: Aetna CPB 0185 — Breast Reconstructive Surgery

Coverage criteria

  • Reconstruction after a medically necessary mastectomy or lumpectomy that results in a significant deformity, where the mastectomy/lumpectomy was performed for (ONE of): treatment of or prophylaxis against breast cancer; OR chronic, severe fibrocystic breast disease (cystic mastitis) unresponsive to medical therapy
  • Autologous fat grafting: harvesting (via lipectomy or liposuction) and grafting of autologous fat as a replacement for implants for breast reconstruction, or to fill defects after breast conservation surgery or other reconstructive techniques
  • Breast asymmetry correction in Poland Syndrome: surgical correction of chest wall deformity causing functional deficit when criteria in CPB 0272 are met
  • Post-mastectomy/lumpectomy asymmetry: medically necessary procedures on the non-diseased/unaffected/contralateral breast to produce a symmetrical appearance — may include areolar and nipple reconstruction, areolar and nipple tattooing, augmentation mammoplasty, augmentation with implantation of FDA-approved internal breast prosthesis when the unaffected breast is smaller than the smallest available internal prosthesis, breast implant removal and subsequent re-implantation when performed to produce a symmetrical appearance, breast reduction by mammoplasty or mastopexy, capsulectomy, capsulotomy, and reconstructive surgery revisions
  • Prompt repair of breast asymmetry due to trauma
  • Medically necessary procedure: capsulectomy
  • Medically necessary procedure: capsulotomy
  • Medically necessary procedure: implantation of FDA-approved internal breast prosthesis
  • Medically necessary procedure: mastopexy
  • Medically necessary procedure: insertion of breast prostheses
  • Medically necessary procedure: tissue expanders
  • Medically necessary procedure: latissimus dorsi (LD) myocutaneous flap reconstruction
  • Medically necessary procedure: Rubens flap
  • Medically necessary procedure: superficial inferior epigastric perforator (SIEP) flap
  • Medically necessary procedure: superior or inferior gluteal free flap
  • Medically necessary procedure: transverse upper gracilis (TUG) flap
  • Medically necessary procedure: transverse rectus abdominis myocutaneous (TRAM) flap
  • Medically necessary procedure: deep inferior epigastric perforator (DIEP) flap
  • Medically necessary procedure: superficial inferior epigastric artery (SIEA) flap
  • Medically necessary procedure: superior gluteal artery perforator (SGAP) flap
  • Medically necessary procedure: profunda artery perforator flap
  • Medically necessary procedure: similar procedures, including skin sparing techniques
  • Medically necessary procedure: autologous fat harvesting and grafting
  • Medically necessary procedure: associated nipple and areolar reconstructions and tattooing
  • Medically necessary procedure: reduction (or augmentation in some cases) mammoplasty and related procedures on the unaffected side for symmetry
  • Medically necessary acellular dermal matrix: Alloderm (LifeCell Corp., Branchburg, NJ)
  • Medically necessary acellular dermal matrix: Alloderm-RTU (LifeCell Corp., Branchburg, NJ)
  • Medically necessary acellular dermal matrix: Cortiva (formerly AlloMax, NeoForm) (Davol, Inc., Warwick, RI)
  • Medically necessary acellular dermal matrix: DermACELL (Novadaq Technologies, Bonita Springs, FL)
  • Medically necessary acellular dermal matrix: DermaMatrix (Musculoskeletal Transplant Foundation/Synthes CMF, West Chester, PA)
  • Medically necessary acellular dermal matrix: FlexHD (Musculoskeletal Transplant Foundation/Ethicon, Inc., Somerville, NJ)
  • Medically necessary acellular dermal matrix: Strattice (LifeCell Corp., Branchburg, NJ)
  • Medically necessary acellular dermal matrix: SurgiMend (TEI Biosciences, Boston, MA)

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Frequently asked questions

When does Aetna cover Breast Reconstructive Surgery (CPT 19316), and what gets it denied?
Aetna CPB 0185 covers breast reconstruction (including flap procedures, implants/tissue expanders, autologous fat grafting, nipple/areolar reconstruction and tattooing, listed acellular dermal matrices, and symmetry procedures on the unaffected breast) when it follows a medically necessary mastectomy or lumpectomy that causes significant deformity — done for breast cancer treatment/prophylaxis or for severe fibrocystic disease unresponsive to therapy — or to correct asymmetry from Poland syndrome or trauma. Several newer techniques and matrices (e.g., SimpliDerm, nerve coaptation, intraoperative hypothermia, 3D volumetric imaging, venous super-charging) are experimental/investigational, and reconstructive surgery for any indication not listed is considered cosmetic and not covered. The bulletin does not address precertification. Coverage criteria include: Reconstruction after a medically necessary mastectomy or lumpectomy that results in a significant deformity, where the mastectomy/lumpectomy was performed for (ONE of): treatment of or prophylaxis against breast cancer; OR chronic, severe fibrocystic breast disease (cystic mastitis) unresponsive to medical therapy; Autologous fat grafting: harvesting (via lipectomy or liposuction) and grafting of autologous fat as a replacement for implants for breast reconstruction, or to fill defects after breast conservation surgery or other reconstructive techniques; Breast asymmetry correction in Poland Syndrome: surgical correction of chest wall deformity causing functional deficit when criteria in CPB 0272 are met; Post-mastectomy/lumpectomy asymmetry: medically necessary procedures on the non-diseased/unaffected/contralateral breast to produce a symmetrical appearance — may include areolar and nipple reconstruction, areolar and nipple tattooing, augmentation mammoplasty, augmentation with implantation of FDA-approved internal breast prosthesis when the unaffected breast is smaller than the smallest available internal prosthesis, breast implant removal and subsequent re-implantation when performed to produce a symmetrical appearance, breast reduction by mammoplasty or mastopexy, capsulectomy, capsulotomy, and reconstructive surgery revisions; Prompt repair of breast asymmetry due to trauma; Medically necessary procedure: capsulectomy; Medically necessary procedure: capsulotomy; Medically necessary procedure: implantation of FDA-approved internal breast prosthesis; Medically necessary procedure: mastopexy; Medically necessary procedure: insertion of breast prostheses; Medically necessary procedure: tissue expanders; Medically necessary procedure: latissimus dorsi (LD) myocutaneous flap reconstruction; Medically necessary procedure: Rubens flap; Medically necessary procedure: superficial inferior epigastric perforator (SIEP) flap; Medically necessary procedure: superior or inferior gluteal free flap; Medically necessary procedure: transverse upper gracilis (TUG) flap; Medically necessary procedure: transverse rectus abdominis myocutaneous (TRAM) flap; Medically necessary procedure: deep inferior epigastric perforator (DIEP) flap; Medically necessary procedure: superficial inferior epigastric artery (SIEA) flap; Medically necessary procedure: superior gluteal artery perforator (SGAP) flap; Medically necessary procedure: profunda artery perforator flap; Medically necessary procedure: similar procedures, including skin sparing techniques; Medically necessary procedure: autologous fat harvesting and grafting; Medically necessary procedure: associated nipple and areolar reconstructions and tattooing; Medically necessary procedure: reduction (or augmentation in some cases) mammoplasty and related procedures on the unaffected side for symmetry; Medically necessary acellular dermal matrix: Alloderm (LifeCell Corp., Branchburg, NJ); Medically necessary acellular dermal matrix: Alloderm-RTU (LifeCell Corp., Branchburg, NJ); Medically necessary acellular dermal matrix: Cortiva (formerly AlloMax, NeoForm) (Davol, Inc., Warwick, RI); Medically necessary acellular dermal matrix: DermACELL (Novadaq Technologies, Bonita Springs, FL); Medically necessary acellular dermal matrix: DermaMatrix (Musculoskeletal Transplant Foundation/Synthes CMF, West Chester, PA); Medically necessary acellular dermal matrix: FlexHD (Musculoskeletal Transplant Foundation/Ethicon, Inc., Somerville, NJ); Medically necessary acellular dermal matrix: Strattice (LifeCell Corp., Branchburg, NJ); Medically necessary acellular dermal matrix: SurgiMend (TEI Biosciences, Boston, MA). Applies to 22 codes: 19316, 19318, 19325, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 15769, 15771, 15772, 15773, 15774. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Policy exclusions and limitations: Experimental, investigational, or unproven (insufficient evidence to support effectiveness of the approach): Artia Reconstructive Tissue Matrix; Experimental, investigational, or unproven: Biodesign Nipple Reconstruction Cylinder; Experimental, investigational, or unproven: body lift perforator flap technique for breast reconstruction; Experimental, investigational, or unproven: intraoperative hypothermia in breast reconstruction; Experimental, investigational, or unproven: nerve coaptation for improvement of sensation following breast reconstruction; Experimental, investigational, or unproven: pre-operative computed tomographic angiography in planning thoraco-dorsal artery perforator flap in breast and soft tissue reconstruction; Experimental, investigational, or unproven: SimpliDerm (human acellular dermal matrix) (Azyi Biologics Inc., Silver Spring, MD) for breast reconstruction surgery; Experimental, investigational, or unproven: three-dimensional (3D) volumetric imaging and reconstruction of breast or axillary lymph node; Experimental, investigational, or unproven: venous super-charging in autologous breast reconstruction with abdominal-based flaps; Cosmetic (not covered): Aetna considers breast reconstructive surgery to be cosmetic for all other indications not listed above. Claims may be denied when the requested service falls under these.
Does Aetna require prior authorization for Breast Reconstructive Surgery?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.
What does Aetna exclude for Breast Reconstructive Surgery?
Policy exclusions and limitations: Experimental, investigational, or unproven (insufficient evidence to support effectiveness of the approach): Artia Reconstructive Tissue Matrix; Experimental, investigational, or unproven: Biodesign Nipple Reconstruction Cylinder; Experimental, investigational, or unproven: body lift perforator flap technique for breast reconstruction; Experimental, investigational, or unproven: intraoperative hypothermia in breast reconstruction; Experimental, investigational, or unproven: nerve coaptation for improvement of sensation following breast reconstruction; Experimental, investigational, or unproven: pre-operative computed tomographic angiography in planning thoraco-dorsal artery perforator flap in breast and soft tissue reconstruction; Experimental, investigational, or unproven: SimpliDerm (human acellular dermal matrix) (Azyi Biologics Inc., Silver Spring, MD) for breast reconstruction surgery; Experimental, investigational, or unproven: three-dimensional (3D) volumetric imaging and reconstruction of breast or axillary lymph node; Experimental, investigational, or unproven: venous super-charging in autologous breast reconstruction with abdominal-based flaps; Cosmetic (not covered): Aetna considers breast reconstructive surgery to be cosmetic for all other indications not listed above. Claims may be denied when the requested service falls under these.

Source

Aetna CPB 0185 — Breast Reconstructive Surgery

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0185 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.