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. Click here to learn more about your rights 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,” 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 your doctor thinks removing your breast implants is medically necessary, the health insurance policy can refuse to pay if their policy’s definition of medically necessary is different from your 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 ALCL (a rare cancer that can develop around breast implants).
Rupture: If your implants are ruptured, you will need 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 much better to avoid mammography if you can.
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 your body, to protect your 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.
Pain: Pain caused by capsular contracture is often considered justification for insurance coverage of removal. In addition, if your implants are causing extensive pain because of nerve damage or the weight of the implants, it is sometimes possible to get your insurance company to pay for removal.
Improved health after removal: If you can prove that your symptoms have drastically improved after your breast implants were removed, you may be able to make a case that it was medically necessary to remove them in the first place. If you are no longer in pain, or are now able to return to work after being unable to work as a result of complications from your breast implants, you could make a strong case for why the implant removal was needed. However, it is always riskier to pay for implant removal and then hope the surgery will be reimbursed.
What is generally NOT considered “medically necessary”?
Unfortunately, most insurance companies do not consider any autoimmune diseases/symptoms or anxiety related to your implants to be proof that it is medically necessary to remove your breast implants. However, many women who have those symptoms also have other problems, such as leaking silicone implants or capsular contracture. So, focus on the symptoms that the insurance company cares about, not the ones that they don’t cover.
What does “reconstructive surgery” mean?
Some insurance companies will consider your breast implant removal “reconstructive surgery” as opposed to “cosmetic surgery” and therefore medically necessary when the purpose of your surgery is to treat a medical condition. This usually means that you have Baker grade III or IV capsular contracture, and/or limited movement affecting your ability to do simple tasks such as reaching above your head or combing your hair. Your breast implant removal may also be considered reconstructive if you have lumps of silicone in the breast area that interfere with the diagnosis of breast cancer.
How do I know when/if my insurance plan considers breast implant removal “medically necessary”?
To find out what your insurance plan covers, you can read through a copy of your actual policy. There are often 3 versions of your health insurance policy:
- A short summary, also called a Summary of Benefits and Coverage. This will not have the information you need.
- A description of the plan. This will have more information than the summary, will probably specify that cosmetic surgery is not covered, and may even mention breast implants specifically. However, it usually will not have the specific information you need to know if your policy will cover implant removal.
- The specific policies regarding breast implants or cosmetic surgery complications are in the “contract” that you sign when you buy health insurance coverage. This contract has all the very specific policies that you need to know about. As a customer who bought that policy, you are entitled to receive a copy online or in the mail, so you can call to ask for it. If your current insurance policy does not cover implant removal, you should shop around to look for one that does. However, that can be difficult to find out.
Persistence can make a difference! For example, Medicare denied Karen’s initial claim for breast implant removal because they concluded that explanting her ruptured silicone gel implants was not medically necessary. In her appeal, she sent copies of several insurance policies from other companies, stating that they cover surgical removal of silicone gel breast implants when they are ruptured. Medicare finally granted her coverage for her explant surgery. Karen is already feeling better than she had in months/years.
We would be happy to help you with this. To start that process, you can fill out our very short survey here: https://www.surveymonkey.com/s/KHCWGM8
What do I need from my doctor?
When the time comes to ask the insurance company for coverage, it helps if your doctor sends a letter to your insurance company detailing why removal of your breast implants is medically necessary. He/she should focus on the complications that you have that are more likely to be covered by your insurance (such as implant rupture or Baker III or IV capsular contracture). It is usually better to not talk about your other symptoms (such as autoimmune symptoms), because it will detract from what the insurance company needs to hear.
What if I have Medicare?
Your doctor should be able to call Medicare’s provider line to check if your breast implant removal surgery will be covered.
Q: My implants are silicone, they were implanted before 2007, and my insurance has denied coverage to remove my implants (or I have no insurance or Medicaid). I do not have Medicare. Can you help me?
If this is the case, you may be eligible for a financial assistance program to help you afford your breast implant removal. Please visit www.oplc.org and download the Notice of Interest form. If you have any questions, you can contact the Program Administrator, Jeff Condra, at email@example.com or 205-252-6784.
What do I need to know about breast implant removal surgery?
See our article here.