Does Insurance Cover Breast Implant Removal?

Posted July 22, 2024 in Breast Implants, Insurance

5 Min Read:

As much as you may feel ready for a surgical procedure, there is always a cost to be considered. Due to their elective nature, cosmetic surgeries are usually not covered by health insurance. However, there are some cases where breast implant removal is considered medically necessary and may be covered. This blog will discuss the difference between medical and non-medical reasons for breast implant removal, how to gather documentation and navigate insurance claims, and other financing options for breast explant surgery.

Reasons for Breast Implant Removal

There are many reasons patients opt to remove their breast implants. In terms of insurance coverage, it’s useful to categorize these as either medical or non-medical.

Medical Reasons

Many insurance companies will not cover cosmetic surgeries, and some even disqualify complications from previous procedures from insurance coverage. However, most insurance companies will cover implant removal but nothing else.

There are specific conditions for which many insurance companies consider the removal of breast implants to be medically necessary, including:

• Complications: Common breast implant complications include ruptured silicone implants or severe capsular contracture.
• Infection: An infection that doesn’t go away may count as a medically necessary reason to have breast implants removed.
• Cancer concerns: Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a cancer of the immune system and is typically considered a medically necessary reason for breast implant removal. Additionally, breast implants that were part of reconstructive surgery after a mastectomy may qualify for insurance coverage for their removal.
• Chronic breast pain: Many insurance companies consider chronic breast pain to be a medically necessary reason for breast implant removal if it affects daily activities.

Unfortunately, often insurance companies will not cover the cost of breast explant surgery when it comes to autoimmune or connective tissue diseases. For example, Breast Implant Illness (BII) is a condition where many women experience symptoms like chronic fatigue, joint pain, and cognitive issues that they attribute to their implants. However, BII is not universally recognized as legitimate in the medical community. When it comes to filing a claim, it’s best to focus on conditions that will be covered.

Non-Medical Reasons

Not everyone gets their implants removed due to health concerns. Some non-medical reasons for removing breast implants include:

• Aesthetic preference: A change in aesthetic preference, whether it’s size, implant material, or dissatisfaction with the results of breast augmentation, may cause some patients to seek breast explant surgery.
• Lifestyle change: Career changes, life events, or even a simple desire for a more natural look might influence a person’s decision to have their implants removed.

Non-medical reasons like these are not viable reasons for insurance companies to cover your breast implant removal surgery.

When Does Insurance Cover Breast Implant Removal?

As discussed above, when a service is considered medically necessary, an insurance company is more likely to cover its cost. Medical necessity is defined by how essential a procedure is in treating or preventing a serious health issue. In the case of breast implant removal, the above issues are likely to be covered by many insurance companies.

Breast reconstruction surgery after mastectomy has special regulations under the Women’s Health and Cancer Rights Act of 1998. If the mastectomy procedure was covered by insurance, then additional coverage of breast reconstruction surgery and implant removal, if necessary, is often required by law.

Documentation and Evidence

To increase your chances of insurance coverage, it’s important to document your case thoroughly. This includes:

• Medical records that document complications or symptoms related to the breast implants;
• A recommendation from your doctor explaining why this procedure is medically necessary;
• Diagnostic testing results that support your case, including MRI, ultrasound, or biopsy;
• Photographic evidence of physical complications, like capsular contracture or infection.

Working with your doctor to submit an insurance pre-authorization request to your insurance company is also recommended as further justification for your procedure.

Navigating Insurance Claims

It can be difficult to deal with insurance companies, but you can make the process smoother with the following strategies:

1. Understand your policy. Read your policy thoroughly to understand what is covered and what is not. You can also search the document for language concerning cosmetic surgery, breast implant removal, or complications. You can use “Control + F” to bring up a search box on an electronic copy. Words like “breast,” “cosmetic,” or “medically” can help you locate specific information.
2. Consult your healthcare provider. Your primary care physician or plastic surgeon can provide valuable assistance during this process, including help with documentation, letters of medical necessity, and guidance on necessary diagnostic tests.
3. Appeal denials. If your claim is denied, you have a right to appeal. Gather the necessary documentation, write a detailed appeal letter, and get support from your doctor or healthcare provider. Many insurance claims that were initially denied are overturned upon appeal.
4. Consider legal advice. Consulting with a healthcare attorney may be beneficial if you presented strong evidence of medical necessity and were denied. They can provide valuable legal advice and help you challenge the insurance company’s decision.

Diligence and preparation are required when navigating insurance policies and appeal denials, but advocating for your health and well-being is well worth it.

Financing Options

If all else fails, there are options to help cover the cost of breast implant removal for those without insurance coverage.

1. Payment plans: See if your surgeon offers payment plans that split the cost of surgery over several months.
2. Medical credit cards: Healthcare credit cards, like CareCredit, often have promotions and special offers pertaining to interest rates and can help you finance medical procedures.
3. Personal loans: Banks or credit unions can help provide funds for surgery.
4. Health Savings Accounts (HSAs): If you have an HSA or a Flexible Spending Account (FSA), you can apply these funds to the cost of surgery.

Breast Implant Removal in Palos Verdes, CA

Dr. Boyd is a board-certified plastic surgeon with extensive experience. He and his team are happy to help guide you through the process if you are considering breast implant removal. Fill out our online contact form or call (310) 597-4734 today to schedule a consultation.