Alyssa Lane
Whether or not health insurance covers breast implant removal depends on the patient's original reason for getting the implants and the insurance company's definition of medically necessary. If the implants were put in after a mastectomy, and a doctor believes that removing them is medically necessary, then health insurance is legally obligated to cover the procedure. However, if the original reason for getting breast implants was for augmentation of healthy breasts, then some health insurance companies will cover explant surgery if they consider the services to be medically necessary, but others will not.
| Characteristics | Values |
|---|---|
| Insurance coverage for breast implant removal | Depends on the insurance company and the reason for the original implant |
| Reasons for coverage | Medical necessity, complications from implants, mastectomy |
| Reasons for denial of coverage | Cosmetic surgery, no medical necessity |
| Documentation required | Evidence of Coverage/Benefits Booklet, letter from the treating doctor, insurance claim form, supporting documentation from doctors |
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What You'll Learn
Insurance companies consider the original reason for getting breast implants
When it comes to breast implant removal, insurance companies consider several factors, including the original reason for getting the implants. The original reason for breast implants plays a crucial role in determining insurance coverage for their removal. If the implants were put in for augmentation of healthy breasts, some insurance companies may cover the explant surgery if they deem it "medically necessary." On the other hand, if the implants were placed after a mastectomy due to breast cancer, health insurance is legally obligated to cover the removal if a doctor believes it is medically necessary.
It is important to note that insurance companies have different definitions of "medically necessary." In the context of breast implant removal, it refers to the essential nature of the procedure in treating or preventing a serious health issue. For example, complications such as ruptured silicone implants or severe capsular contracture are generally considered medically necessary reasons for removal by insurance companies. Capsular contracture occurs when scar tissue forms around the implant and then tightens or hardens, causing discomfort or pain.
Chronic breast pain that interferes with daily activities is another reason insurance companies may consider breast implant removal medically necessary. Additionally, infections that do not heal and cancer concerns, such as Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL), may also fall under this category. However, it is important to remember that insurance companies do not typically consider autoimmune diseases, anxiety, or connective tissue issues as proof of medical necessity for implant removal.
To increase the chances of insurance coverage, individuals should thoroughly document their cases and seek pre-authorization from their insurance companies. Consulting with a healthcare attorney can also be beneficial if strong evidence of medical necessity is presented and the claim is denied. It is always advisable to communicate directly with the insurance provider to understand their specific policies and requirements regarding breast implant removal coverage.
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Capsular contracture
The presence of capsular contracture can lead to discomfort and a distorted breast shape. In more severe cases, it can result in debilitating pain and even nerve damage. While light capsular contracture (Baker I or II) is generally not considered a reason for surgical intervention, more advanced cases (Baker III or IV) may be deemed medically necessary for implant removal.
Insurance companies typically consider severe capsular contracture, resulting in chronic pain and movement limitations, as a valid reason for implant removal. This condition is often classified as reconstructive surgery rather than cosmetic surgery, making it eligible for insurance coverage. However, the decision to cover the procedure ultimately depends on the insurance company's definition of "medical necessity" and their specific policies.
To increase the likelihood of insurance coverage for capsular contracture treatment, it is essential to focus on the recognised complications, such as severe pain and limited movement, rather than symptoms that insurance companies typically do not cover, like autoimmune issues. Obtaining a pre-authorisation from the insurance company, based on the patient's symptoms and diagnosis, is a crucial step before undergoing surgery. Nevertheless, even with pre-authorisation, coverage is not guaranteed and depends on the actual procedure performed.
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Medically necessary
Breast implant removal may be covered by medical insurance if it is deemed medically necessary. This means that the procedure is performed to address a health issue or complication caused by the implants, rather than for purely cosmetic reasons.
There are several scenarios in which breast implant removal may be medically necessary. This includes situations where the implants have ruptured or leaked, causing
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Cosmetic surgery
Whether or not health insurance covers breast implant removal depends on the reason for the surgery. Health insurance never covers cosmetic surgery, which is surgery performed for purely cosmetic or aesthetic reasons. However, if a physician deems the procedure to be medically necessary, then health insurance may cover it.
If a patient's breast implants were put in following a mastectomy, and a doctor believes that removing the implants is "medically necessary", then health insurance is legally obligated to cover the breast implant removal.
If the original reason for getting breast implants was for augmentation of healthy breasts, then some health insurance companies will cover explant surgery if they consider the services to be "medically necessary", but others will not.
Insurance companies have policies or guidelines that determine if they will cover breast implant removal procedures. Most insurance companies will not cover any cosmetic procedures, and some will not cover complications from previous cosmetic procedures.
If a patient is experiencing capsular contracture, which can cause discomfort and a distorted shape to the breasts, insurance will sometimes cover implant removal, and sometimes not. Light capsular contracture (usually Grade 1 or 2, or Baker I or Baker II) is generally considered to be too insignificant to require surgery. However, painful capsular contracture with lots of scar tissue, or Baker III or Baker IV, may be covered.
If a patient is experiencing symptoms of autoimmune disorders, such as fatigue, muscle and joint aches, fevers, dry eyes and mouth, and occasionally poor memory or concentration, most insurance companies will not consider these to be proof that it is medically necessary to remove the breast implants. However, many women who have these symptoms also have other problems, such as leaking silicone implants or capsular contracture, which may be covered by insurance.
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Complications from breast implants
One of the most common complications is capsular contracture, which occurs when scar tissue forms and tightens or hardens around the implants. This can cause discomfort or debilitating pain and may require removal of the implants. Other complications include chronic breast pain, rupture of the implant, hematoma or bleeding, infection, seroma, necrosis of the nipple or areola, and implant malfunction. Some patients may also experience implant leakage, sweating, or extrusion, or issues with wound healing.
In terms of insurance coverage for breast implant removal due to complications, it depends on the individual's health insurance plan and the company's definition of "medically necessary." Most insurance companies will not cover cosmetic surgery or its complications but may deem implant removal medically necessary if there are severe complications such as Baker III or IV capsular contracture, implant rupture, or chronic pain. It is important to note that some insurance companies may not consider autoimmune diseases, anxiety, or aesthetic concerns as valid reasons for removal.
To increase the likelihood of insurance coverage, individuals should focus on the complications that insurance companies typically cover and obtain a letter from their doctor detailing the medical necessity of the removal. It is also advisable to communicate directly with the insurance provider to understand their specific coverage policies regarding breast implant removal.
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Frequently asked questions
It depends on the insurance company and the reason for the surgery. If the implants were put in after a mastectomy, and a doctor believes that removing the implants is "medically necessary", then health insurance is legally obligated to cover the breast implant removal. If the original reason for getting breast implants was for augmentation of healthy breasts, then some health insurance companies will cover the surgery if they consider the services to be "medically necessary", but others will not.
"Medically necessary" means that a physician has deemed a surgical procedure to be necessary based on prudent, evidence-based standards of care. However, every insurance company defines this term differently to meet state requirements for what procedures health insurance companies are legally bound to cover.
Most insurance companies do not consider any autoimmune diseases/symptoms or anxiety related to the implants to be proof that it is medically necessary to remove the breast implants.
When asking the insurance company for coverage, your doctor will need to send a letter to the insurance company detailing why the removal of breast implants is medically necessary.
