T85.49XS Insurance Policy Changes

ICD-10 T85.49XS is officially defined as "Other mechanical complication of breast prosthesis and implant, sequela." code T85.49XS is referenced in 3 tracked payer policy changes from Independence Blue Cross, Aetna, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code T85.49XS is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Independence Blue Cross · Effective Jul 9, 2025Medium impact
MA11.076g, Removal of Breast Implants
Independence Blue Cross updated MA11.076g to MA11.076h, removing coverage language that previously allowed reconstruction/replacement of breast implants for traumatic or surgically created deficits. CPT code 19370 was removed, and ICD-10 diagnosis codes were updated to add BIA-ALCL and gynecomatia-related codes while removing sequela and prosthetic status codes. The policy now emphasizes that removal is covered only when medical necessity criteria are met, with symmetry coverage available only when one implant requires removal due to a covered indication.
Aetna · Identified Aug 14, 2026Medium impact
Breast Implant Removal (CPB 0142, reviewed 2026-03-19)
Aetna considers breast implant removal medically necessary for members who had cosmetic augmentation or breast reconstruction after a medically necessary mastectomy and who meet at least one listed criterion. The criteria include breast cancer in the implanted or contralateral breast where implant removal is necessary to excise the cancer, breast implant-associated anaplastic large cell lymphoma, implant extrusion through the skin, recurrent infections, Baker Class IV contracture associated with severe pain, severe contracture that interferes with mammography, intra- or extra-capsular rupture of silicone gel-filled implants, cutaneous hypersensitivity-like reactions that failed conventional treatments, and persistent pain, lumps, swelling or asymmetry in textured implants after the surgical incision has fully healed. Requests for removal for Baker Class III contracture that does not follow a medically necessary mastectomy, for a biopsy of a breast mass not proven to be cancerous, or for a mastectomy or lumpectomy that can be performed with the implant in place are subject to medical review. Aetna does not consider IgG testing in connection with silicone implants medically necessary, and it does not consider removal of silicone implants for autoimmune disease medically necessary unless a selection criterion is met.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Augmentation Mammoplasty
This Blue Cross Blue Shield policy states that benefits are specifically excluded when augmentation mammoplasty is performed for cosmetic purposes. Augmentation may be considered reconstructive in listed situations, including agenesis or severe hypoplasia with a 50% or greater deformity of the contralateral breast, scoliosis, Poland's syndrome, chest wall deformity such as pectus excavatum, breasts damaged by infection, traumatic loss, scarring, burns or X-ray therapy, and reconstruction after mastectomy for cancer. The 03/27/2026 policy update removed the ICD-9 procedure and diagnosis codes.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code T85.49XS?

There are 3 tracked policy changes affecting code T85.49XS, including updates from Independence Blue Cross, Aetna, Blue Cross & Blue Shield of Mississippi. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code T85.49XS?

Payers that have issued tracked updates for code T85.49XS include: Independence Blue Cross, Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when code T85.49XS policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code T85.49XS. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for code T85.49XS?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

All billing codes J3590 C9399 J3490 99215 99213 99202

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MA11.076g, Removal of Breast Implants

Breast Implant Removal (CPB 0142, reviewed 2026-03-19)

Augmentation Mammoplasty

What insurance policy changes affect code T85.49XS?

Which payers have updated policy for code T85.49XS?

How do I get notified when code T85.49XS policy changes?

Why do payers change policies for code T85.49XS?