First of all, the original reason for getting your breast implants matters to health insurance companies (as well as Medicare and Medicaid).
If your implants were put in after a mastectomy and your doctor believes that removing your implants is “medically necessary,” then your health insurance is legally obligated to cover your breast implant removal under the Women’s Health and Cancer Rights Act of 1998 (WHCRA).
If the original reason for getting breast implants was for augmentation of healthy breasts, then some health insurance companies will cover your explant surgery if they consider the services to be “medically necessary.”
What are “Medically Necessary” Services?
Insurance companies cover services that they determine to be “medically necessary” to treat a disease or illness. Although you or your doctor may believe a service is medically necessary, insurance companies don’t always agree.
Most insurance companies will not cover any cosmetic procedures and some will not cover complications from previous cosmetic procedures. However, many companies consider removal of breast implants medically necessary for patients with any of these conditions:
- Ruptured silicone gel breast implants
- Severe capsular contracture
- Infections that don’t go away
- Chronic breast pain
- Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL), a cancer of the immune system)
Unfortunately, insurance companies usually won’t cover the cost of breast implant removal for autoimmune or connective tissue diseases or other systemic complications. If you have any of the conditions listed in the bullets above, you should focus on those in your insurance claim because insurance companies are more likely to cover these symptoms.
How do I know whether my insurance company will cover the cost of removal?
To find out if your insurance company is likely to cover removal, you will need to look at your specific policy language. You can usually find this language in a document called “Evidence of Coverage” (EOC), this is also sometimes called a “Benefits Booklet.” It is a document (typically about 100 pages) that describes in detail the healthcare benefits covered by your health plan, including procedures that your insurance company will and will not cover.
You can access an electronic copy of your EOC through your online account on your insurance company’s website. You can also call the member services number on the back of your insurance card and ask an insurance representative for a copy of this document.
What Do I Look For?
Once you have your policy, look for language about breast implant removal. If you don’t see any language about breast implant removal, search for language on complications from cosmetic surgery. If you cannot find any specific language about breast implant removal, you should also look to see what your insurance company’s definition of “medically necessary” is. It is also important to check whether your insurance plan requires pre-authorization for any surgeries.
If you’re using an electronic copy, you don’t need to read the entire document. You can easily find terms using the “Control+F” keys on your keyboard. That will provide a “search box” that will search for any words you enter. Just enter the word “breast” or “cosmetic” or “medically” in the search box. If you are unable to find what you need in the lengthy document, call your member services line and ask for assistance to locate the correct pages.
File for Pre-Authorization
Most insurance companies will require that you get pre-authorization (also called prior approval or pre-certification) before the surgery. This means your insurance company reviews your relevant information and determines whether surgery is medically necessary. Then, the insurance company will let you know if it is likely to cover your surgery. However, that pre-authorization isn’t a promise that your surgery will be covered.
The easiest way to get pre-authorization is to have your plastic surgeon sign and submit a letter that lists your symptoms and explains why removal is medically necessary based on your insurance policy language. (Usually one or more of health problems listed on the bullets earlier in this article). Your surgeon should also enclose any medical documentation that provides proof of your symptoms.
It is best if your plastic surgeon signs this letter to send with your insurance claim. However, if your surgeon is unwilling to sign the letter, another doctor involved with your care, such as your primary care provider, can sign. You can find templates for these letters here. If your doctor agrees to sign the letter, but won’t submit it to your insurance company, you will need to submit the letter before your surgery to ensure you receive pre-authorization.
NOTE: If you don’t get pre-authorization when it was required, the insurance company isn’t required to cover the surgery, even if it considers the procedure to be medically necessary.
After Your Surgery: Filing a Reimbursement Claim
If your surgeon is in your insurance company network, he/she should file a claim on your behalf. If not, you will have to pay upfront for the surgery and file the reimbursement claim with your insurance company. Even if you see a surgeon who doesn’t take insurance, you should still file a pre-authorization claim with your insurance company. If you didn’t seek pre-authorization before your surgery, you can still file a reimbursement claim.
In your reimbursement claim, you will need to submit your pre- and post-operative reports, along with a letter from the surgeon stating that the procedure was medically necessary.
You can learn more about getting private insurance to cover your explant surgery, including how to appeal a denial, here on our breast implant information website.
What if I have Medicare?
Medicare usually covers breast implant (saline or silicone) removal for any of these conditions:
- Painful capsular contracture with disfigurement
- Implant rupture
- Implant extrusion (coming through the skin)
- Interference with the diagnosis of breast cancer
- Siliconoma or granuloma (silicone-filled lumps under the skin)
Medicare coverage can differ depending on the state where you live. You can check the specific Medicare policies on breast implants removal in your state here.
You can learn more about getting Medicare to cover your explant surgery here on our breast implant information website.
You can learn more about getting Medicaid to cover your explant surgery here on our breast implant information website.
What do I Need to Know about Breast Implant Removal Surgery?
See our article here.
All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.
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