Insurance Coverage Assistance

Some insurance companies realize that removal of breast implants can be medically necessary for women’s health to improve and will offer policies to cover the removal surgery. Obtain a copy of your insurance policy and review it to see if they are likely to pay for the removal. Generally, the insurance criteria focus on capsular contractures, ruptures, infections, and chronic breast pain. Accompany one or more medical necessity letter(s) with the specific insurance codes, some are listed below. See Sample Medical Necessity Letter and Private Insurance Help by the National Center for Health Research. The process of getting approved may require tenacity and perseverance, if you get denied the first time repeal as many times as necessary. Do not get discouraged, one woman reapplied three times and then was approved. The key with insurance is really to be persistent. If you have exhausted the appeals procedure, you can file a complaint with the state insurance commissioner. Finally, if all else fails, you can hire an attorney to write your insurance a letter for failing to cover a medically necessary procedure.

Insurance companies that have covered women:

  • Aetna – Breast implant Removal
  • Aultcare: OH
  • Blue Cross Blue Shield: AZ, FL (covered 90%), MI, MN, NM, NY, OK, WA, CA.
    • BCBS AZ covers explants as of February 2019. Here is the specific content that was changed: “Removal of a breast implant for any non-cosmetic, medical complication or consequence, whether immediate or delayed, that arises from a prior cosmetic breast implant is considered medically necessary and eligible for coverage.”
    • BCBS CA PPO, doctor submitted notes of exam to insurance and discussed chest and breast pain.
    • BCBS MN covered an explant of a woman with capsular contracture (Baker Grade IV in one breast and II in the other).
  • Cigna: CO, TN, UT
  • Community Care of OK
  • Kaiser
  • Medi-Cal
  • Moda: WA
  • SelectHealth insurance in Utah (Select Med plan)
    • Helped cover partial costs of explant for a woman. She did not have rupture or capsular contracture but she did have pain.
  • Tricare: CO, OK (Tricare Standard)
  • UCare: MN.
    • Patient was able to have the explant covered, did not have capsular contracture but did complain of pain.
  • United Healthcare: Coverage Determination, now covers explants for Allergan recalled textured breast implants (August 2019 update).
  • Tufts Health Direct through Health Connector in MA covers removal if there is a rupture or one has been diagnosed with an autoimmune disorder.
  • Provincial Health (Alberta Health Care, Canada)

Please note that policies vary by state and coverage depends on your specific medical circumstances.

Kantor & Kantor – Explants Denied by Insurance Claims:  

Kantor & Kantor law firm in California was able to get an explant insurance denial overturned. See Coverage for Breast Explant Surgery Was Denied – Kantor & Kantor Stepped In and Got the Denial Overturned (June 2019).

They are now interested to speak to women who have had to pay out-of-pocket for explant and have had explant insurance denials from: BCBS California, BCBS of Illinois, BCBS of Montana, BCBS of New Mexico, BCBS of Oklahoma, and BCBS of Texas. Please contact attorney Cari Schwartz if you meet these case criteria and are interested in filing a lawsuit, her contact number is (818) 886-2625.

National Center for Health Research 

The National Center for Health Research is a nonprofit organization assisting women who seek health insurance coverage or Medicare coverage for the medically necessary removal of their breast implants. They can be contacted by email at [email protected]. Sample of a message women have received from them is: “If you are having problems with your breast implants, we want to help you succeed in getting health insurance coverage so you can get them removed as soon as possible.  Please reply if you’d like our help!”

Breast Implant Information Organization 

Another resource for assistance in the insurance process is Breast Implant Information, sponsored by the National Center for Health Research. If you would like their assistance, please take this short survey, and they should be in touch with you. Or you can also contact them at [email protected] or (844) 295-2212. They recommend taking the following steps and can assist you with them:

  1. Send them a copy of your insurance policy so they can review it.
  2. Get a consultation with plastic surgeon who is experienced in explant.
  3. Ask your surgeon/doctor if they can write a letter of medical necessity and help you file a claim.
  4. File your claim with the relevant medical documents, medical necessity letter, and insurance codes.
  5. If you get approved, congratulations! If you get denied, appeal as many times as necessary.

Mastectomy Cases

“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).”1 

Medicare and Medicaid 

Medicare and Medicaid will often cover the costs of breast implant removal. If you have applied or are on Social Security Disability Insurance (SSD/SSDI) or Supplemental Security Income (SSI) you may be able to have the costs of explantation covered by them. The problem with Medicare is that they do not preapprove anything. Your local Medicare or Medicaid office is likely to have a list of plastic surgeons that accept their coverage. Ensure they will remove the implants with full capsule removal, via en bloc or total capsulectomy.

According to Centers for Medicare & Medicaid Services (CMS), which is the government program that regulates Medicare services, Medicare authorizes the removal of breast implants for the following reasons:

2. Removal of BREAST IMPLANTs
For a patient who has had an implant(s) placed for reconstructive or cosmetic purposes, Medicare considers treatment of any one or more of the following conditions to be medically necessary:
•Broken or failed implant
•Infection
•Implant extrusion
•Siliconoma or granuloma
•Interference with diagnosis of breast cancer
•Painful capsular contracture with disfigurement

Source: Cms.gov Medicare Coverage Database

See: Will Medicare Pay to Remove My Breast Implants? by the National Center for Health Research

Insurance companies would save on years or decades of unnecessary medical costs by recognizing the necessity of explant surgery as a cost effective protocol to prevent further systemic illness.

Insurance Codes:

CPT

19371-50 – Periprosthetic capsulectomy, breast – the 50 modifier is for – Bilateral Procedure

ICD 10

T85.49XA – Other mechanical complication of breast prosthesis and implant, initial encounter
T85.79XA – Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts
T85.848A – Pain due to internal prosthetic devices, implants and grafts
T85.44XA – Contracture of Breast Prosthesis
T85.43XA – Rupture of Breast Prosthesis
N64.81 – Breast Ptosis
N64.4 – Mastodynia

International:

South Africa Explant Insurance Coverage:

Medihelp Necesse Package covered a woman’s explant in full when she had a breast ultrasound and it confirmed that the implants leaked, as a note it took three ultrasounds to finally detect the leak. Momentum covered most of another woman’s explant when she had her surgeon write them a letter emphasizing two large lumps. Additionally, the Bone and Breast Care Centre comes recommended for specializing in breast scans and reports. See above for codes to submit to insurance, South Africa uses some of the same ones as the U.S.

UK Explant Insurance Coverage:

Some women have had success with having the NHS cover their explant. One woman went to her doctor and explained the pain and discomfort she was in and was referred to a hospital breast clinic where she then had her explant. In consideration of this option, please ensure full capsule removal.

Netherlands Explant Insurance Coverage: 

Zorginstituut Nederland sent a memo to all health insurance companies in May 2018. They state that when a woman has health issues that do not go away with treatment that explant should be paid through insurance. Therefore, if you can show a history of doctor visits and have systemic symptoms, explant should be covered.