Are you wondering if health insurance will cover your breast implant removal? The contracts and rules vary, but in general, the insurance company will first look at the original reason for which you got the implants.
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 the doctor thinks removing the breast implants is medically necessary, the health insurance policy can refuse to pay if their policy’s definition of medically necessary is different from the doctor’s.
The most generous health insurance policies regarding breast implant removal are usually based on one of the following conditions:
What is generally not considered “medically necessary”?
Unfortunately, most insurance companies do not consider any autoimmune diseases/symptoms or anxiety related to the implants to be proof that it is medically necessary to remove the breast implants. However, many women who have those symptoms also have other problems, such as leaking silicone implants or capsular contracture. Focus on the symptoms that the insurance company cares about, and not the ones that they don’t cover.
What does “reconstructive surgery” mean?
Some insurance companies will consider breast implant removal “reconstructive surgery” as opposed to “cosmetic surgery” and therefore medically necessary when the purpose of the surgery is to treat a medical condition. This usually means that there is Baker grade III or IV capsular contracture, and/or limited movement affecting the ability to do simple tasks such as reaching above the head. The breast implant removal may also be considered reconstructive if there are lumps of silicone in the breast area that interfere with the diagnosis of breast cancer.
What do I need from my doctor?
When the time comes to ask the insurance company for coverage, Fox Valley Plastic Surgery sends a letter to the insurance company detailing why removal of breast implants is medically necessary. The focus is on the complications that are more likely to be covered by insurance (such as implant rupture or Baker III or IV capsular contracture), and not on other symptoms (such as autoimmune symptoms) that the insurance company will not cover.