Breast implants can significantly improve a woman’s life. Breast implants are used by roughly 10 million to 11 million women worldwide, according to the American Society of Plastic Surgeons and the Plastic Surgeon Foundation. According to the American Society of Plastic Surgeons, over 400,000 women and teenagers have breast implant augmentation procedures each year, with 75% of them for enhancement of healthy breasts and 25% for reconstruction after mastectomy.
Women have suspected that their breast implants have made them quite sick in recent years. Symptoms of autoimmune disorders, such as weariness, muscle and joint aches, fevers, dry eyes and mouth, and occasionally poor memory or concentration, continue to be reported by breast implant recipients.
Unfortunately, most women who want their breast implants removed for medical reasons will be denied coverage by their health insurance. Breast “explant” surgery is not covered by health plans because it is “not medically required” or is restricted by plan restrictions. Dealing with your insurance carrier to get therapy covered can be frustrating and time-consuming. When dealing with insurance providers, knowledge is power. Here are some pointers to help you get the most out of your insurance for breast explant surgery.
Your Insurance Policy
If you’re wondering if your health insurance will cover breast implant removal, the best answer is that it depends on your specific policy. Because every insurance company handles cosmetic surgery procedures differently, and because breast implant removal is considered cosmetic surgery, you’ll need to examine your plan’s list of covered benefits to see how much, if any, your insurance company will pay for this procedure.
Locate your “Evidence of Coverage” document, often known as a “Benefits Booklet,” to find your insurance company’s particular policy on breast implant removal. This brochure spells out exactly what is and isn’t covered by your plan. You’ll want to check for information about breast implant removal if your firm doesn’t provide it, but if it doesn’t, look under “Beauty surgery.” Also, look up the definition of in your plan “Medically required.”
General Policy Guidelines
Despite the fact that you should check with your particular insurance company to see if breast implant removal is covered, there are a few basic ways that the majority of insurance companies pay this treatment. First and foremost, your insurance will want to know why you had breast implants in the first place. This will serve as the beginning point for determining whether the removal operation will be covered.
Implants After a Mastectomy
If you had your breast implants placed after a mastectomy to remove your natural breasts, your insurance company may be compelled to pay for their removal. Your doctor must believe that removing your implants is medically required and must be able to persuade your insurance company that it is. This means that there is a medical reason to have them removed that will improve your health or cure a condition caused by the implants.
Implants for Augmentation
Even if removal is deemed medically necessary, your insurance provider may or may not cover your breast implants if you acquired them for enhancement purposes. This is due to the fact that many insurance companies do not cover cosmetic surgery or its repercussions. As a result, no matter what explanation you offer for having your breast implants removed, they will not provide coverage, even if they are making you unhealthy or causing other medical problems.
Exceptions
Do not give up if your insurance company initially rejects your claim for breast implant removal. Many insurance companies make exceptions to their policy for complications from breast implants (as opposed to other cosmetic surgical treatments) if they meet certain criteria or are judged medically necessary under reconstructive surgery restrictions. This will necessitate the collaboration of your physician in establishing medical necessity with the insurance company, as the latter will require documented verification of the requirement.
Medically Necessary Conditions
As previously stated, the word “medically necessary” refers to a physician’s decision to perform a surgical operation based on reasonable, evidence-based standards of care. However, each insurance company defines this term differently in order to comply with state laws about which operations health insurance companies must cover by law. Keep in mind that insurance companies are in the business of making money, so getting borderline medically required operations approved isn’t always straightforward.
It’s also crucial to understand that even if your doctor thinks your breast implant removal operation is medically necessary, your insurance company may disagree and refuse to pay for it. Health insurance plans that have previously covered for breast implant removal have determined that the treatment is medically required based on one or more of the symptoms listed below, which must also be documented by your physician.
Ruptured Silicone Gel Implants
Despite the fact that ruptured silicone gel implants are not thought to cause breast cancer or other significant problems such as infertility or rheumatoid arthritis, they can cause excruciating breast agony. If you detect lumps, hardness, or swelling in your breast, or if the form or size of your breast changes, it’s possible that one of your implants has burst. However, there are situations when there are no symptoms at all.
Your doctor will need to provide you confirmation of a burst implant, which will most likely come in the form of an MRI or ultrasound. A mammogram may be able to detect a rupture, but because mammograms can cause previous implants to rupture or leak, or exacerbate a present leak, an MRI or ultrasound is a superior diagnostic technique. Your doctor will almost certainly need to establish that the leak is causing you medical problems as well.
Baker III or Baker IV Capsular Contracture
The most common consequence of silicone or saline breast implants is capsular contracture, which causes pain, hardness, and numbness in the breasts. Scar tissue builds around the implants as your body’s natural response against a foreign substance, causing this. A grade three capsular contracture is characterized by firmness, misshapenness, and discomfort in the breast. The breast is rigid, deformed, and painful with a grade four capsular contracture.
Capsular contracture grades one and two are usually not regarded medically required grounds to remove breast implants. The breast will be supple and a grade one capsular contracture will be scarcely apparent. The breast is slightly firmer in a grade two capsular contracture, but there is no pain or discomfort. Chronic pain from capsular contracture (grades III and IV), especially if it’s causing nerve damage, is a common justification for implant removal when it’s medically essential.
Infection or Breast Implant-Associated Anaplastic Large Cell Lymphoma
You may need to have your implants removed if you get an infection in your breasts as a result of your implants, or if you develop a condition known as Breast Implant-Associated Anaplastic Large Cell Lymphoma, or BIA-ALCL. BIA-ALCL is an uncommon type of immune system cancer detected in the scar tissue surrounding the implants. It is not breast cancer. It has the potential to spread to lymph nodes and, if left untreated, can be lethal.
Not Medically Necessary
While insurance companies differ in what they consider medically necessary, what is not medically necessary is obvious. Breast implant removal procedure is usually not covered by insurance if it is causing autoimmune disease symptoms or anxiety. Recent research suggests that people who have breast implants have a higher frequency of autoimmune illness diagnoses than those who do not have implants. Lupus, scleroderma, and rheumatoid arthritis are among them.
Most insurance companies are unaware of the potential relationship between autoimmune disorders and breast implants because the link is currently shaky, despite the fact that it has a name (Breast Implant Illness). This ailment has no diagnosis code, so it cannot be claimed on a medical bill. However, many women who have BII or anxiety due to breast implants also have another problem like as a leak or capsular contracture, which may be covered by insurance.
Reconstructive Surgery vs. Cosmetic Surgery
If your physician suggests the removal of breast implants due to a medical condition, this type of removal would be considered as reconstructive surgery rather than aesthetic surgery and would be reimbursed by your insurance carrier. The most common medical problem associated with breast implants is pain or significant movement restrictions. It’s likely that getting your breast implants removed because they’ve gotten deformed is still considered cosmetic surgery.
If there are silicone lumps that are interfering with the capacity to diagnose breast cancer, reconstructive surgery rather than cosmetic surgery may be recommended. This is especially true if you have signs of breast cancer but a mammography can’t “see” through the silicone or if the silicone is blocking medical professionals from taking a biopsy from a probable tumor. Your doctor may advise you to have your implants removed to avoid a more serious problem.
Does insurance pay for implant removal?
Are you wondering if your health insurance will cover the cost of removing your breast implants? Although contracts and rules differ, in general, the insurance company will look at the original purpose for the implants.
- If the implants were placed after a mastectomy and the doctor thinks they should be removed, “If the breast implant removal is deemed “medically essential,” health insurance is compelled to pay for it.
- If the original purpose of the breast implants was to enhance the appearance of healthy breasts, some health insurance companies will fund explant surgery if the services are deemed necessary “Others, however, will not consider it “medically necessary.”
What if my insurance provider says “cosmetic surgery issues” aren’t covered?
Don’t let yourself down. Almost all health insurance coverage exclude “cosmetic surgery” and “cosmetic surgery consequences,” but don’t give up. Many insurance make exceptions for issues from breast implants if they are deemed “medically required” or “reconstructive surgery” in certain instances.
Varied health insurance companies have different definitions for this, and it also differs by state.
Even if the doctor believes that removing the breast implants is medically required, the health insurance policy could refuse to pay if the policy’s definition of medically necessary differs from the doctor’s.
Most of the most generous health insurance coverage for breast implant removal are based on one of the following conditions:
- Baker III or Baker IV capsular contracture is caused by silicone or saline implants.
- Breast implants that need to be removed due to infection or BIA-ALCL (Breast Implant-Associated Anaplastic Large Cell Lymphoma, an immune system disease).
- Rupture: If the implants have ruptured, proof is required. Implant ruptures are best measured with MRIs, however ultrasounds or mammograms may also be used. Mammography, on the other hand, can cause existing breast implants to shatter or leak, and it is not particularly accurate at identifying rupture, so it is best to avoid it.
- Breast implants are a “foreign body,” and most women’s bodies naturally respond by forming scar tissue around the implant inside the body to defend the body from this “foreign invader.” This is a natural occurrence. When the scar tissue around the implants tightens or hardens, it is referred to as capsular contracture. Breast implants made of saline or silicone can cause capsular contracture. It can make you feel a little uneasy or cause excruciating agony. The mildest form of capsular contracture is known as “Baker I” or “Baker II” (after Dr. Baker, who created the classifications), whereas the most severe is known as “Baker III” or “Baker IV.” Breasts that are Baker III or Baker IV are hard and/or painful. Baker III and/or Baker IV level capsular contracture is usually only considered a medically required reason for removal by insurance carriers.
- Chronic Breast Pain: Capsular contracture pain is frequently stated as grounds for insurance coverage of breast excision. Furthermore, if the implants are causing severe discomfort due to nerve damage or the weight of the implants, the insurance company may be able to cover the cost of removal.
Unfortunately, most insurance companies do not consider any autoimmune diseases/symptoms or anxiety related to the implants as indication that removing the implants is medically essential. Many women with those symptoms, however, also have other issues like leaky silicone implants or capsular contracture. Concentrate on the symptoms that the insurance company is interested in, rather than the ones that aren’t covered.
When the objective of the surgery is to remedy a medical condition, some insurance companies will consider breast implant removal “reconstructive surgery” rather than “cosmetic surgery” and thus medically required. This usually indicates Baker grade III or IV capsular contracture, as well as restricted movement that makes it difficult to perform simple actions like reaching over the head. If there are silicone lumps in the breast area that interfere with the identification of breast cancer, breast implant removal may be considered restorative.
When it’s time to approach the insurance company for coverage, Fox Valley Plastic Surgery writes the insurance company a letter explaining why breast implant removal is medically required. The emphasis is on complications that are more likely to be reimbursed by insurance (such as implant rupture or Baker III or IV capsular contracture), rather than symptoms that the insurance company will not pay (such as autoimmune symptoms).
How much does it cost to explant?
According to the American Society of Plastic Surgeons’ 2020 figures, the average cost of breast implant removal operation is $3,049. This is only a portion of the entire cost; it excludes anesthesia, operating room facilities, and other related costs.
How much does it cost to remove and replace breast implants?
According to the American Society of Plastic Surgeons, the average cost of breast implant removal surgery is $2,641.
The total cost of the surgery, including the surgeon’s fee, is shown here. Additional costs, such as anesthesia and facility fees, are not included.
Keep in mind that you may incur additional post-surgery expenses, such as recovery drugs and post-surgery undergarments.
While most medical insurance policies do not cover the cost of breast augmentation surgery, your insurer may cover the cost of implant removal in certain instances.
This could be the situation if your doctor determines that implant removal is medically necessary because the implants are posing a health risk.
If you meet the following conditions, your insurance company may cover all or part of the cost of breast implant removal surgery:
Your insurance company most likely has a policy that dictates how much it will pay for breast implant removal surgery.
However, if you only want the surgery for cosmetic reasons, insurance is unlikely to cover the cost.
Will insurance cover ruptured breast implant?
If the implants are put for cosmetic reasons, the insurance company will normally only pay for the removal and/or capsulectomy of the implants, as well as for ruptured implants or uncomfortable capsular contracture. This does not involve implant replacement or dealing with the loose skin and sagging breast tissue that can result from removing an implant without replacing it.
The problem with having your insurance carrier cover implant removal is that they frequently deny payment after the surgery is completed, leaving the patient responsible for the surgeon’s fee, anesthesia fee, and O.R. fee, all of which are significantly higher than the fee charged if the procedure had been performed as a cosmetic procedure.
Also, to avoid any misunderstanding, we normally don’t charge for implant removal if a capsulectomy or mastopexy (breast lift) is performed concurrently as a cosmetic treatment. Any inquiries you may have will be gladly answered by our office.
How long is recovery after explant surgery?
How long does it take to recover from breast implant surgery? Some of your normal activities, such as driving, should be avoided for the first one to two weeks after surgery. You should avoid intense activities and heavy lifting during your rehabilitation. For up to six weeks, many people experience pain or soreness.
How much does it cost to remove an implant?
The cost of a birth control implant, commonly known as Nexplanon, can range from $0 to $1,300. The cost of implant removal varies from $0 to $300. The good news is that most health insurance plans, Medicaid, and certain other government programs cover implants for free (or at a modest cost).
Even while the implant is more expensive up front than other options, it saves you money in the long run because it lasts for 5 years.
If cost is a concern, contact your local Planned Parenthood health center to see if they can assist you in finding birth control that suits your budget.
Planned Parenthood can also assist you in obtaining health insurance, as most insurance plans are required to include birth control at no cost to you under the Affordable Care Act (commonly known as Obamacare). Learn more about birth control and health insurance.
Is a breast lift necessary after implant removal?
Every woman who has had her breast implants removed does not require a breast lift or mastopexy. The requirement for a breast lift after breast implant removal is determined by the size of the implant and the elasticity of your skin. When bigger implants, which cause severe skin stretching, are removed, the skin may not retract fully.
Can breast tissue grow back after implant removal?
After the explant operation, the breasts will restore their volume in around 3 weeks. The final results, though, could take up to a year to appear. Breasts may not restore their original appearance after augmentation surgery, particularly if the implants have been in place for a long time and the breast tissue is thin. Filling out of the breasts and softening of the breasts (sometimes known as “fluffing”) may occur 6-9 months following cosmetic surgery.
How long can you leave a ruptured implant?
It’s debatable whether or not to remove a broken implant. A damaged implant is the most common cause of late capsular contracture. We find a lot more silicone granulomas and calcium deposits when a damaged implant is left in for a long time. I don’t believe it is life-threatening, but it should be removed as soon as possible to avoid more difficulties. Implants typically last 10 years. Best wishes to you.
Do I need a lift after explant?
It’s difficult to predict how a woman’s breasts and nipples will look once the implants are removed, and whether or not a breast lift will be required. When breast implants are removed, some women’s breasts appear flat, sagging, and shapeless. Other women’s breasts are noticeably smaller once the implants are removed, although not always saggier.
After implant removal, ladies whose breasts lie low on the chest or whose nipples point downward should consider a breast raise. The breasts are lifted to a more youthful posture on the chest, and the nipples are raised higher on the breasts.
The extent to which your breast tissue and skin have stretched out or sagged determines whether you require a breast lift in your circumstance. If you haven’t had your breasts augmented in a long time or have really large implants, you’re likely to experience some breast sagging once the implants are removed. However, if your skin is supple, you have little implants, and it hasn’t been a long time since your breast augmentation, you may not require a lift after the implants are removed.
The best method to acquire answers on how to proceed is to schedule an in-person assessment with Dr. Greenwald and discuss your goals. Dr. Greenwald and you can determine how to approach your operation together. You can have a lift at the same time as your implants are removed, or you can wait until your breasts have settled and your body has healed before deciding how to proceed, based on how your breasts look and your desired cosmetic result.