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Insurance Coverage for Implant Removal

Are you wondering if health insurance will cover your breast implant removal? The contracts and rules vary, but in general, the insurance company will first look at the original reason for which you got the implants.

• If the implants were put in after a mastectomy, and the 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.

What if my insurance company says that “complications from cosmetic surgery” are not Included?
Don’t be discouraged. Almost all health insurance policies will not cover “cosmetic surgery” or “complications from cosmetic surgery” but don’t give up so easily. Many policies have exceptions for complications from breast implants under certain circumstances that they consider “medically necessary” or “reconstructive surgery.”

What are “medically necessary” services?
This is defined differently by different health insurance companies, and sometimes varies in different states as well.

It is important to understand that even if the doctor thinks removing the breast implants is medically necessary, the health insurance policy can refuse to pay if their policy’s definition of medically necessary is different from the doctor’s.

The most generous health insurance policies regarding breast implant removal are usually based on one of the following conditions:

• Silicone gel implants that are proven to be ruptured.
• Silicone or saline implants that are causing Baker III or Baker IV capsular contracture.
• Breast implants that are causing necrosis (death of skin or tissue).
• Breast implants that need to be removed because of infection or Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL), a cancer of the immune system)
• Rupture: If the implants are ruptured, there needs to be proof. MRIs are the best measurement of implant ruptures, but ultrasounds or mammograms may be accepted too. However, the pressure from mammography can cause old breast implants to break or leak, and are not very accurate for detecting rupture, so it is better to avoid mammography.
• Capsular Contracture: Breast implants are a “foreign body” and the natural response for most women is that the body forms scar tissue around the implant inside the body to protect the body from this “foreign invader.” This is a natural process. However, it is called capsular contracture when the scar tissue tightens or hardens around the implants. Capsular contracture can happen with either saline or silicone breast implants. It can feel slightly uncomfortable or cause debilitating pain. The mild version of capsular contracture is called “Baker I” or Baker II” (named after a Dr. Baker who devised the categories) and the most severe is called “Baker III or Baker IV.” Baker III or Baker IV breasts are hard and/or painful. Insurance companies usually only consider Baker III and/or Baker IV level capsular contracture to be a medically necessary reason for removal.
• Chronic Breast Pain: Pain caused by capsular contracture is often considered justification for insurance coverage of removal. In addition, if the implants are causing extensive pain because of nerve damage or the weight of the implants, it is sometimes possible to get the insurance company to pay for removal.

What is generally not considered “medically necessary”?
Unfortunately, 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. However, many women who have those symptoms also have other problems, such as leaking silicone implants or capsular contracture. Focus on the symptoms that the insurance company cares about, and not the ones that they don’t cover.

What does “reconstructive surgery” mean?
Some insurance companies will consider breast implant removal “reconstructive surgery” as opposed to “cosmetic surgery” and therefore medically necessary when the purpose of the surgery is to treat a medical condition. This usually means that there is Baker grade III or IV capsular contracture, and/or limited movement affecting the ability to do simple tasks such as reaching above the head. The breast implant removal may also be considered reconstructive if there are lumps of silicone in the breast area that interfere with the diagnosis of breast cancer.

What do I need from my doctor?
When the time comes to ask the insurance company for coverage, Fox Valley Plastic Surgery sends a letter to the insurance company detailing why removal of breast implants is medically necessary. The focus is on the complications that are more likely to be covered by insurance (such as implant rupture or Baker III or IV capsular contracture), and not on other symptoms (such as autoimmune symptoms) that the insurance company will not cover.