Whether it’s for health purposes or other reasons, if you’re considering having your breast implants removed by Palms Wellington Plastic Surgery in Wellington, FL., you know this procedure can be expensive. You may be wondering if your health insurance will cover the removal of breast implants so that you can save some money. The answer is a bit complicated, but in some cases, you may be able to get some insurance coverage for this procedure.
Will Insurance Cover Removal of Breast Implants?
Your Insurance Policy
The best answer for whether your health insurance will cover breast implant removal is that it depends on your individual insurance policy. The reason we can’t give a simple “yes” or “no” answer is because every insurance company handles cosmetic surgery procedures differently, and since breast implant removal is considered cosmetic surgery, you’ll have to consult your plan’s list of covered benefits to determine how much, if any, your insurance company will pay toward this procedure.
To find your insurance company’s specific policy on breast implant removal, you need to locate your “Evidence of Coverage” document, which may also be called a “Benefits Booklet.” This booklet provides explicit language on what is and is not covered in your plan. You will want to find any information on breast implant removal, but if your company does not get that specific, look under “cosmetic surgery.” Additionally, also find your plan’s definition of “medically necessary.”
General Policy Guidelines
Despite the fact that you’ll need to verify the coverage of breast implant removal with your own insurance company, there are some common ways in which this specific procedure is covered by the majority of insurance companies. To begin with, your insurer will want to know the reason why you received breast implants in the first place. This will be the starting point for discussions on whether or not the removal procedure will be covered.
Implants After a Mastectomy
If you had your breast implants put in following a mastectomy to remove your natural breasts, your insurance company may be required to cover your removal of breast implants. Your physician must believe that removing your implants is medically necessary and be able to convince your insurer that their removal is medically necessary. This means that there is a medical reason for removing them that by doing so, will improve your health or will cure a condition the implants caused.
Implants for Augmentation
If you originally received your breast implants for augmentation purposes, your insurance company may or may not cover these, even if removal is considered medically necessary. This is because many insurance companies do not cover cosmetic surgery or complications from cosmetic surgery. As such, no matter the reason you give for getting your breast implants removed, even if they are making you unhealthy or causing other medical issues, they will not provide coverage.
Even if your insurance company initially denies your claim for breast implant removal, do not give up right away. Many insurance companies have exceptions to their policies for complications from breast implants (as opposed to other cosmetic surgery procedures) if they meet certain circumstances under reconstructive surgery parameters or are deemed medically necessary. This will require your physician’s cooperation to establish medical necessity with the insurance company, as the company will want documented proof of the need.
Medically Necessary Conditions
As mentioned briefly above, the term “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. Keep in mind that insurance companies are in the business of making money, so they don’t always make it easy for patients to get borderline medically necessary procedures covered.
It’s also important to know that even if a physician believes your breast implant removal procedure is medically necessary, the insurance company may not agree and can refuse to pay for the surgery. Health insurance plans that have paid for the removal of breast implants in the past have deemed the procedure medically necessary based on one or more of the following conditions, which must also be documented by your physician.
Ruptured Silicone Gel Implants
Even though ruptured silicone gel implants are not believed to cause breast cancer or other serious conditions like infertility or rheumatoid arthritis, they can cause breast pain that can sometimes be unbearable. You may be able to tell if one of your implants has ruptured if you develop lumps, hardness, or swelling in your breast, or if you notice your breast has changed shape or size. Sometimes, though, there are no symptoms at all.
Your physician will need to provide proof of a ruptured implant, most likely through an MRI or ultrasound. A mammogram may also be able to show a rupture, but since mammograms can cause old implants to rupture or leak or make a current leak worse, an MRI or ultrasound is a better diagnostic tool for this purpose. Additionally, your physician will probably need to show that the leak is causing medical issues for you as well.
Baker III or Baker IV Capsular Contracture
Capsular contracture is the most common complication of silicone or saline breast implants and can lead to pain, hardness, and numbness in the breasts. This occurs because of scar tissue that forms around the implants as your body’s natural defense to a foreign object. A grade three capsular contracture means the breast is firm, misshapen, and uncomfortable. A grade four capsular contracture means the breast is hard, misshapen, and painful.
Grades one and two of capsular contracture are typically not considered medically necessary reasons to remove breast implants. A grade one capsular contracture will barely be noticeable and the breast will be soft. A grade two capsular contracture features a slightly firm breast, but no pain or discomfort. Chronic pain associated with capsular contracture (grades III and IV), especially if it’s resulting in nerve damage, is often justification for medically necessary implant removal.
Infection or Breast Implant-Associated Anaplastic Large Cell Lymphoma
If an infection develops in the breasts due to your implants, or you develop a condition called Breast Implant-Associated Anaplastic Large Cell Lymphoma or BIA-ALCL, you may need to have your implants removed. BIA-ALCL is not breast cancer but is instead a rare kind of immune system cancer that is found in the scar tissue surrounding the implants. It can spread to the lymph nodes and if left untreated, can even be fatal.
Not Medically Necessary
While the conditions that are considered medically necessary vary among insurance companies, what is not medically necessary is clear. Generally, insurance companies will not cover breast implant removal surgery if it is causing autoimmune disease symptoms or anxiety. There is some evidence based on recent research that people who have breast implants have a higher incidence of autoimmune disease diagnoses than people who have not had implants. These include lupus, scleroderma, and rheumatoid arthritis.
Since the link between autoimmune diseases and breast implants is currently tenuous, even though it even has a name (Breast Implant Illness), most insurance companies do not recognize this potential connection. There is no diagnosis code for this condition, so it cannot even be claimed on a medical bill. That being said, many women who suffer from BII or anxiety related to breast implants also often have another condition such as a leak or capsular contracture that may be covered.
Reconstructive Surgery vs. Cosmetic Surgery
You may be able to get the removal of breast implants covered by your insurance company if your physician recommends their removal due to a medical condition, in which case, this type of removal would be classified as reconstructive surgery rather than cosmetic surgery. The main medical condition related to breast implants is pain or severe movement limitations. If you want to get your breast implants removed because they’ve become misshapen, this would likely still be considered cosmetic surgery.
Another condition that may be considered reconstructive surgery instead of cosmetic surgery is if there are silicone lumps that are interfering with the ability to diagnose breast cancer. This is especially the case if there are indications you may have breast cancer, but a mammogram cannot “see” through the silicone or if the silicone is preventing medical professionals from getting a biopsy from a potential tumor. To prevent a more serious condition, your physician may recommend your implants be removed.
Getting Breast Implant Removal Covered
If you’ve searched your policy information and have found that breast implant removal may be covered based on medical necessity and you have been diagnosed with a ruptured implant, capsular contracture (grade III or IV), or Breast Implant-Associated Anaplastic Large Cell Lymphoma, or your physician has provided another reason why your surgery is medically necessary, the next step will be to have your physician get a pre-authorization from your insurance company.
A pre-authorization is a statement that your insurance company has reviewed your case and decided to authorize surgery based on your symptoms and diagnosis. You must obtain a pre-authorization before you get your surgery done, and even if you get it pre-authorized, it doesn’t mean your surgery is guaranteed to be covered. It still depends on the actual procedure performed and restricts your physician to the procedure that has been pre-authorized. Any deviation from this plan may nullify the pre-authorization.
What Is Needed for Pre-Authorization?
The most straightforward path to pre-authorization is to have your physician document your symptoms and diagnosis, and, along with supporting evidence like MRI or ultrasound results, sign and submit a letter requesting pre-authorization to your insurance company. This letter should explain why the procedure is medically necessary as defined by your health insurance company. It’s best if your actual surgeon provides this information, but it can come from any of your treating physicians, including your primary care physician.
You are also able to request pre-authorization yourself, but will still need to provide proof from your medical records and a statement of medical necessity from your physician. Just remember that you must get this pre-authorization prior to your surgery. Otherwise, the insurance company is under no obligation to cover any part of your surgery, and if it does cover some of it, you may end up paying more than you would have with the pre-authorization.
Even if you’re not sure if your insurance company will cover breast implant removal, you should consult with a professional to discuss your situation. There are many reasons why people in West Palm Beach choose to get their implants removed, and the best source of information regarding coverage is a clinic that specializes in cosmetic surgery. Contact Palms Wellington Plastic Surgery in Wellington, FL. today to schedule your initial consultation.