Will Insurance Cover Breast Implant Removal
Discover what options your insurance carrier may or may not provide and how to approach them. Also, keep in mind that removing breast implants can come at a cost and there are strict rules that must be followed if you’re seeking reimbursement from a health insurance provider.
In this guide, we find out: Will Insurance Cover Breast Implant Removal, grants for breast implant removal, how to get insurance to pay for breast augmentation, and What are the options for breast implant removal?
Getting breast implants can change a person’s life for the better. According to the American Society of Plastic Surgeons and the Plastic Surgeon Foundation, approximately 10 million to 11 million women in the world have breast implants. The American Society of Plastic Surgeons estimates that more than 400,000 women and teenagers undergo breast implant augmentation surgeries every year, with 75% for augmentation of healthy breasts and 25% for reconstruction after mastectomy.
In recent years, women have suspected that their breast implants have made them very ill. Breast implant recipients continue to report symptoms similar to those of autoimmune disorders including fatigue, muscle and joint aches, fevers, dry eyes and mouth, and occasionally poor memory or concentration.
Unfortunately, most women who want their breast implants removed for medical reasons and want their health insurance to cover it, will be denied coverage. Health plans refuse to pay for breast “explant” surgery on the grounds that such treatment is “not medically necessary,” or is limited by plan terms. Dealing with your insurance company to get the treatment covered can be confusing and complicated. Knowledge is power in dealing with insurance companies. Below are some tips to help you maximize coverage for breast explant surgery.
Know Your Coverage
It is important that you are familiar with your insurance policy. If you get health insurance through your employer (even if you pay some of the premium), you should request a copy of your insurance policy from your employers’ human resources department.
If you have an individual insurance policy, you can request a copy of your policy from your insurance company.
Pay Attention to Important Plan Terms
Below are some important plan terms that you will likely see in your policy. Make sure you understand these terms and how they apply to your situation:
What is Medical Necessity?
Health benefits are only provided for services that are “medically necessary.” Insurance companies have policies or guidelines that decide 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.
Some guidelines are available on insurance company websites, but in some cases, you may need to ask for them. Familiarize yourself with the medical necessity guidelines that are being used by your plan. Discuss the guideline with your surgeon to see how it applies to your treatment. Is the treatment medically necessary based on the guidelines? If you are submitting an appeal, then explain this answer in your appeal.
How to Request Pre-Authorization?
To get pre-authorization you will need to submit an insurance claim form and any supporting documentation from your plastic surgeon or doctors. Your health care team may help with this process. The insurance company will review your request and determine whether the surgery is “medically necessary.” If you don’t get pre-authorization when it is required, the insurance company isn’t required to cover the surgery, even if it considers the procedure to be medically necessary. However, pre-authorization isn’t a promise that your surgery will be covered.
Reimbursement Claims & Post-Service Claims
If your request for pre-authorization was denied and your surgeon is an in-network provider, the provider should file a post-service claim on your behalf after the surgery is performed. If, on the other hand, your surgeon is an out-of-network provider or does not accept insurance, you should file a post-service claim or reimbursement claim on your own. Check your plan to find out where to send the claim. In addition to the claim, you or your surgeon should also submit pre- and post-operative reports, bills or invoices, and a letter from the surgeon explaining why the procedure was medically necessary.
Appeals and Denials
If your plan denies coverage or a pre-authorization, it is important to understand your appeal rights and deadlines. These are in your policy and in denial letters. If your claim is denied, put your appeal in writing and submit it on time with a method of delivery confirmation. Submit treatment records with your appeal. Even better, submit a letter from your treating doctor explaining why your treatment is medically necessary based on the insurance company’s guidelines. Keep a copy of the appeal you submitted to the insurance company for your records.
Despite your best efforts, the appeal may be denied. It happens. It is frustrating. Do not lose hope. Appeal again. Usually, policies provide for two levels of appeal (know your policy).
Know when the second-level appeal is due. It could be as soon as 60 days, or as long as 180 days. As another alternative, your plan may offer an External Review. For more information about the appeals process, see our Health Insurance Appeals Module on CancerFinances.org.
Don’t Give Up
If you have exhausted your plan’s appeals process and your claim has still been denied, then litigation may be an option. It might be time to contact a lawyer.
Navigating insurance denials for breast explant surgery can be confusing and feel overwhelming. Don’t feel embarrassed to ask for help if needed.
Cari Schwartz is a senior associate with Kantor & Kantor, LLP. Kantor & Kantor is a contingency law firm that works with individuals and their families to ensure health benefits get paid. Cari represents clients seeking health benefits pursuant to individual policies and is proud to serve on Triage Cancer’s Legal Advisory Council.
Will Insurance Cover Breast Implant Removal
Getting breast implants can change a person’s life for the better. According to the American Society of Plastic Surgeons and the Plastic Surgeon Foundation, approximately 10 million to 11 million women in the world have breast implants. The American Society of Plastic Surgeons estimates that more than 400,000 women and teenagers undergo breast implant augmentation surgeries every year, with 75% for augmentation of healthy breasts and 25% for reconstruction after mastectomy.
In recent years, women have suspected that their breast implants have made them very ill. Breast implant recipients continue to report symptoms similar to those of autoimmune disorders including fatigue, muscle and joint aches, fevers, dry eyes and mouth, and occasionally poor memory or concentration.
Unfortunately, most women who want their breast implants removed for medical reasons and want their health insurance to cover it, will be denied coverage. Health plans refuse to pay for breast “explant” surgery on the grounds that such treatment is “not medically necessary,” or is limited by plan terms. Dealing with your insurance company to get the treatment covered can be confusing and complicated. Knowledge is power in dealing with insurance companies. Below are some tips to help you maximize coverage for breast explant surgery.
Know Your Coverage
It is important that you are familiar with your insurance policy. If you get health insurance through your employer (even if you pay some of the premium), you should request a copy of your insurance policy from your employers’ human resources department.
If you have an individual insurance policy, you can request a copy of your policy from your insurance company.
Pay Attention to Important Plan Terms
Below are some important plan terms that you will likely see in your policy. Make sure you understand these terms and how they apply to your situation:
What is Medical Necessity?
Health benefits are only provided for services that are “medically necessary.” Insurance companies have policies or guidelines that decide 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.
Some guidelines are available on insurance company websites, but in some cases, you may need to ask for them. Familiarize yourself with the medical necessity guidelines that are being used by your plan. Discuss the guideline with your surgeon to see how it applies to your treatment. Is the treatment medically necessary based on the guidelines? If you are submitting an appeal, then explain this answer in your appeal.
How to Request Pre-Authorization?
To get pre-authorization you will need to submit an insurance claim form and any supporting documentation from your plastic surgeon or doctors. Your health care team may help with this process. The insurance company will review your request and determine whether the surgery is “medically necessary.” If you don’t get pre-authorization when it is required, the insurance company isn’t required to cover the surgery, even if it considers the procedure to be medically necessary. However, pre-authorization isn’t a promise that your surgery will be covered.
Reimbursement Claims & Post-Service Claims
If your request for pre-authorization was denied and your surgeon is an in-network provider, the provider should file a post-service claim on your behalf after the surgery is performed. If, on the other hand, your surgeon is an out-of-network provider or does not accept insurance, you should file a post-service claim or reimbursement claim on your own. Check your plan to find out where to send the claim. In addition to the claim, you or your surgeon should also submit pre- and post-operative reports, bills or invoices, and a letter from the surgeon explaining why the procedure was medically necessary.
Appeals and Denials
If your plan denies coverage or a pre-authorization, it is important to understand your appeal rights and deadlines. These are in your policy and in denial letters. If your claim is denied, put your appeal in writing and submit it on time with a method of delivery confirmation. Submit treatment records with your appeal. Even better, submit a letter from your treating doctor explaining why your treatment is medically necessary based on the insurance company’s guidelines. Keep a copy of the appeal you submitted to the insurance company for your records.
Despite your best efforts, the appeal may be denied. It happens. It is frustrating. Do not lose hope. Appeal again. Usually, policies provide for two levels of appeal (know your policy).
Know when the second-level appeal is due. It could be as soon as 60 days, or as long as 180 days. As another alternative, your plan may offer an External Review. For more information about the appeals process, see our Health Insurance Appeals Module on CancerFinances.org.
grants for breast implant removal
However, breast implant illness isn’t the issue that prompted the U.S. Food and Drug Administration (FDA) to request a voluntary recall of manufacturer Allergan’s textured breast implants. The action was intended to protect patients from a different condition—breast implant-associated anaplastic lymphoma (BIA-ALCL).
Now, patients have become increasingly desperate to be free of their implants, but the current healthcare system doesn’t cover the exorbitant cost of implant-removal surgery. Many breast implant patients consequently take matters into their own hands through crowdfunding sites like GoFundMe.
‘I feel like I’m slowly dying’
Late last year, Daniela Sage started experiencing paralyzing pain in her breasts.
The 28-year-old has had silicone implants since 2011, and in recent years, she noticed changes in her body. Her joints ached, she felt chronically tired, and she suffered migraines, hair loss and blurred eyesight.
Sage believes she has breast implant illness.
Though the symptoms mirror those reported by other women, BII is understudied and little understood.
Researchers in the Journal of American Society of Plastic Surgeons called breast implant illness a “challenging issue,” requiring more research and scientific evaluation to better understand how the condition affects people with implants.
Sage, holistic wellness coach based in Miami, Florida, said she no longer felt like the vibrant, energetic individual she once was because of her implant-related illness.
“There have been days when I’ve said it out loud: I feel like I’m slowly dying,” she acknowledged.
When two good friends saw how sick Sage had become, they urged her to start a GoFundMe campaign to pay for immediate implant removal. She wrote on her page about the devastating symptoms of breast implant illness, and the contributions began pouring in.
“In order for me to regain a normal and healthy life, I have no choice but to undergo this surgery or else my health will continue to decline even more, and just the thought alone has me absolutely scared,” Sage wrote on the GoFundMe fundraiser.
Rising Reports of Implant-Related Cancer
In the last year alone, women have filed hundreds of reports to the FDA saying their textured implants led to anaplastic lymphoma, a type of non-Hodgkin’s lymphoma that can be fatal.
The number of reports of implant-related anaplastic lymphoma, or BIA-ALCL, jumped 46 percent between 2017 and 2018 and included 457 doctor-confirmed cases and nine patient deaths attributed to BIA-ALCL, per the FDA’s latest figures.
The possible extent of the problem of BIA-ALCL remains unknown because no one tracks the number of Americans with breast implants. We do know more than a half-million breast implants are used every year, and of those 70,000 are textured, according to estimates from the American Society of Plastic Surgeons(ASPS).
It’s worth noting ASPS appears to undercount the problem of implant-related lymphoma compared to the FDA’s accounting of adverse events. ASPS recognizes only 282 BIA-ALCL cases in the U.S., according to estimates as of May 14, 2019. The FDA updated its estimates after the March 2019 meeting on breast implants, where Madris Tomes, CEO of Device Events, presented an organized data set.
Implants in general, not just the textured form, are also linked to breast implant illness — and have been since the ’90s.
The journey to diagnosis, treatment, and removal in those affected, however, will remain difficult and expensive until the medical industry recognizes BII as a real illness, according to advocates.
How did we get here?
Crowdfunding medical expenses
The average American household spends one-fifth of their income on health care. So it’s no surprise 28 million Americans go without, either because their employer doesn’t provide it or they can’t afford it on their own, the Financial Times reported.
Crowdfunding to shoulder the burden of health-care bills has become a widespread practice, and it’s particularly common for people with breast implants, who face extensive and costly removal surgery.
Sage said her doctor will remove both implants and the surrounding scar tissue in a procedure called an en-bloc total capsulectomy. The procedure aims to rid her body of all of the unhealthy tissue that’s formed around the implants. It amounts to $9,350 in medical costs.
“I simply do not have the funds at the moment and neither does my family,” Sage wrote on the GoFundMe fundraiser page. “These overwhelming emotions are what led me to create this GoFundMe page, in hopes of helping me manifest my surgery in June with your help and donations.”
Campaigns to cover medical expenses account for about a third of all money raised on GoFundMe, although it’s unclear how many fundraisers are for explant surgery like Sage’s, or related to breast implant illness. Sage’s campaign has raised $7,526.95 in contributions both on the platform and off since she launched the fundraiser. Although she has health insurance, she’s paying for the surgery out-of-pocket.
While breast implant illness isn’t currently recognized as a diagnosable medical condition that health insurance will cover, this may change soon.
The FDA is now researching breast implant illness, which is a significant milestone for women with the condition, said Maria Gmitro, an advocate who spoke at an FDA hearing in March on breast implants. The agency is also asking for people to report BII, including the brand name of their implant, implant maker and details of the adverse event.
Drawing inspiration from shared experiences
Sage’s textured breast implants sit on a marble table in Miami, Florida, after her removal surgery on June 14, 2019. Photo by Andrea Sarcos.
Upwards of 4,500 women have had their breast implants removed to treat breast implant illness since 2015, as MedTruth reported. One study found that 75 percent of patients had their silicone breast implants removed enjoyed significant changes in their health.
As Sage waited for her surgery date, she took vitamins and supplements to improve her health. She also avoided foods containing trace amounts of copper after learning she now has copper toxicity.
Throughout her ordeal, Sage said she’s found solace in knowing she’s not alone. She’s drawn inspiration from hearing about other women’s experiences with breast implants, including a woman who shared how her health had rebounded after explant surgery.
“There are thousands of women going through this,” she said. “If you’re open about it and you talk about it, and you share it on your social media, you could be saving another woman’s life. That’s the most important thing — that human connection.”
Post-Explant Surgery
Sage underwent surgery on June 14, 2019. During the nearly four-hour procedure, her surgeon removed two intact capsules and excess scar tissue that had formed around her lymph nodes.
If she’d delayed her surgery any longer, Sage believes her condition could have potentially progressed to lymphoma.
She’s already noticed an improvement in her health, although she’s still recovering. The daily migraines? Gone. Plus, her energy is gradually returning.
“Overall, I just feel a lot more clarity,” she said. “People close to me told me right away I look so much lighter and happier.”
Sage hopes to encourage and inspire women who feel daunted by either the cost of explant surgery, or the fear they’ll look like less of a woman without breast implants.
how to get insurance to pay for breast augmentation
The cost of breast augmentation surgery is one of the main reasons why so many women put off getting breast implants.
Unlike other surgeries, health insurance companies will not cover the costs of breast augmentation surgeries, as they are seen as cosmetic procedures. There are a few exceptions to this rule, particularly for breast reconstruction, but for most women insurance coverage is not an option.
Even though the costs of breast augmentation surgery are becoming more accessible and affordable, it still can be too expensive to pay upfront with cash.
Luckily, today women have more options for financing their breast augmentation surgery, ranging from special care credit cards, personal loans from a bank or credit union, and even online crowdfunding sites.
At Emmett Plastic Surgery, we offer CareCredit, Prosper Healthcare Lending, and a partnership with our local bank, Simmons Bank.
Can breast implants be covered by health insurance?
Women looking to undergo breast augmentation often ask if the procedure is covered by their insurance. Unfortunately, most insurance companies consider breast augmentation to be an elective, or cosmetic surgery and are not willing to cover the costs.
However, for women who have had cancer and received a mastectomy, breast reconstruction surgery may be covered.
Some insurance companies may also cover the costs associated with breast revision surgery, particularly if an implant has ruptured or is causing a rippling texture in the breasts. In these instances, insurance may cover the costs to prevent any health hazards.
We’ve also seen some insurance companies cover breast augmentation for women with asymmetrical breasts, but this may be more difficult depending on your insurance.
Be sure to check your insurance policy for specific language related to cosmetic, elective, and reconstructive surgery.
Breast augmentation financing options
To learn more about financing for augmentation, read our list of financing options to get more ideas on how to fund your breast augmentation surgery.
Your plastic surgeon’s payment plan options
Plastic surgeons know that the price of getting breast implants can be prohibitive to some of their patients. This is why many plastic surgeons offer multiple financing options to make paying for surgery more accessible and sustainable.
At Emmett Plastic Surgery, we offer the three following financing options.
CareCredit®
CareCredit financing has become a very popular choice used by several plastic surgeons and health provider offices across America.
CareCredit is a credit card that provides funding for medical procedures. They offer several different types of cards, depending on the type of procedures and treatments offered.
Their Cosmetic and Beauty Financing credit card helps cover the breast augmentation, as well as other cosmetic surgeries, such as rhinoplasty, liposuction, tummy tuck, mommy makeover, body sculpting, and more.
Like all credit cards, CareCredit comes with a minimum monthly payment.
Simmons Bank
For patients looking to get a personal loan to cover the surgery, we recommend contacting Simmons Bank.
We have an established relationship with Simmons Bank, as they’ve been a Lone Tree, Colorado banking institution for over 14 years.
To contact Simmons Bank Lone Tree office, give them a call at 303-706-1723 and tell them you were referred by Emmett Plastic Surgery.
Prosper® Healthcare Lending
Prosper Healthcare Lending aims to make financing breast augmentation more accessible than ever.
For those wishing to avoid high-interest rates often charged by credit cards, Prosper gives their customers simple installment loans with no retroactive interest.
This means the interest rate will remain fixed and not change, making payments more predictable and affordable to pay off over time.
What are the options for breast implant removal?
Recently, I have received more inquiries at my Northbrook plastic surgery practice regarding breast implant removal surgery. The most common reasons for a woman to choose to have her breast implants removed are health concerns, changes to the implants and the breasts over time, and the feeling that the implants are too large or heavy for her body.
When you choose to have breast implant removal surgery, or breast explant surgery, there are some options available, which you should discuss with a board-certified plastic surgeon. The simplest approach is to remove the implants while leaving the scar tissue capsule in place. A more complex approach is to perform an explant capsulectomy, in which the implants and the scar capsule are removed from the breasts. The most complex option for removing breast implants is an en bloc capsulectomy, in which the implants and scar capsule are removed intact.
Since this is the most complicated option for breast implant removal, I will provide some additional insight into the en bloc capsulectomy procedure.
What is en bloc capsulectomy?
En bloc capsulectomy is a procedure in which the scar tissue around the implant, known as the breast capsule, is removed in one piece with the implant enclosed within it. The benefit of removing the capsule en bloc is that it prevents the implant (or implant material) from coming into contact with normal tissues left behind. This is especially useful in the case of implant rupture but also may benefit those concerned about implant toxicity and breast implant illness. Total capsulectomy means removing the entire capsule but not necessarily in one piece.
En bloc capsulectomy is not a simple procedure. It poses challenges to surgeons and patients alike.
Who is a candidate for en bloc capsulectomy?
Not all patients are candidates for en bloc capsulectomy. On occasion, the capsule is so flimsy (imagine wet toilet paper) that it is impossible to remove in one piece. This is especially true for thin capsular tissue adjacent to the ribcage, where cutting too deep can lead to a punctured lung cavity or prolonged pain. Because of this I rarely guarantee en bloc capsulectomy; but I do promise a good faith effort to remove all of the capsule tissue in a way that minimizes creating additional injury.
How will I look after implant removal surgery?
A lot of women ask whether they will look good after en bloc capsulectomy. This can be a very difficult question to answer. The appearance of the breast depends on its size relative to the implant, the degree to which the breast tissue has been displaced over time, and the degree of skin elasticity that remains. Whether things look good depends on these physical factors, but also on how a woman perceives her “new” breasts in the context of how she feels about her body and whether her breasts play the same role they did when the implants were placed.
In experienced hands, breast lift procedures can go a long way toward restoring a natural breast appearance. However, a lift creates new scars and may be associated with more surgical risk. So it’s really important to make this decision in conjunction with your surgeon, in person, so that you understand what to expect and what other patients like you have experienced. You can see some of my patients’ breast implant removal before and after pictures, with and without breast lifts, to get an idea of the type of results that are often possible.