Insurance Coverage for Breast Implants Explained

Insurance coverage for breast implants can be a complex issue, but understanding the basics can help you navigate the process.

Some insurance plans may cover breast implant removal or revision surgery, but this is typically only if the implants were placed for a medically necessary reason, such as a rupture or capsular contracture.

In the US, the Affordable Care Act (ACA) requires insurance companies to cover breast reconstruction after a mastectomy, but this does not extend to cosmetic breast implant procedures.

Insurance coverage for breast implants varies widely depending on the insurance provider and policy.

Insurance companies consider a procedure medically necessary if it's essential in treating or preventing a serious health issue. This means that if you're experiencing complications, infection, or cancer concerns related to your breast implants, your insurance may cover the cost of removal.

Insurance companies will often cover breast implant removal if it's deemed medically necessary, including complications like ruptured silicone implants or severe capsular contracture, or if you have a chronic condition like chronic breast pain that affects your daily activities.

However, if you're experiencing symptoms like chronic fatigue, joint pain, and cognitive issues that you attribute to your implants, known as Breast Implant Illness (BII), insurance companies may not cover the cost of removal because BII is not universally recognized as legitimate in the medical community.

Insurance companies may require proper documentation to determine if a procedure is eligible for coverage, and it's ultimately up to the discretion of the insurance company.

Here are some specific medical conditions that may qualify for insurance coverage for breast implant removal:

Non-medical reasons for removing breast implants, such as aesthetic preference or lifestyle change, are not viable reasons for insurance companies to cover your breast implant removal surgery.

Insurance coverage for breast implant removal can be complex, but there are some general guidelines to follow. If a service is considered medically necessary, an insurance company is more likely to cover its cost.

Breast reconstruction surgery after mastectomy has special regulations under the Women’s Health and Cancer Rights Act of 1998. This law requires insurance companies to cover breast reconstruction surgery and implant removal if the mastectomy procedure was covered.

Insurance companies have the discretion to decide what is covered, and there are no guarantees. However, some complications, such as rupture or implant capsular contracture, may be eligible for coverage with proper documentation.

To obtain insurance coverage for breast implant removal, it's essential to document the nature of the problem, its severity, character, and length of time it has been ongoing. This includes documenting associated problems and symptoms.

The following complications are not covered by health insurance plans because they do not pose any health hazards:

Capsular contracture, on the other hand, can be covered if it reaches a certain severity. The degree of implant hardening must be documented, and only grades three and four are eligible for coverage.

Here are the characteristics of each capsular contracture grading:

Only grades three and four are covered by insurance plans, which may pay for the capsulectomy or removal of tight scar tissue around the implant and the implant removal. However, insurance companies do not pay for implant replacement, as it is considered elective.

If you're without insurance coverage, don't worry, there are still options to help cover the cost of breast implant removal.

Many surgeons offer payment plans that split the cost of surgery over several months, giving you a more manageable financial burden.

Healthcare credit cards, like CareCredit, often have promotions and special offers that can help you finance medical procedures, including breast implant removal.

Personal loans from banks or credit unions can also provide the funds you need for surgery.

If you have a Health Savings Account (HSA) or a Flexible Spending Account (FSA), you can apply these funds to the cost of surgery, making it easier to cover the costs.

Here are some financing options to consider:

If you're considering breast implants, you'll want to know about related procedures that may be covered by insurance.

Breast lifts, also known as mastopexies, are often performed in conjunction with breast implant surgery to improve the overall appearance of the breasts.

Insurance may cover some or all of the costs associated with a breast lift, depending on the reason for the procedure.

Breast augmentation revision surgery is another related procedure that may be covered by insurance if the original implants are leaking or have ruptured.

Insurance companies often have different policies regarding coverage for breast implant removal or replacement due to capsular contracture.

In some cases, insurance may cover the costs associated with breast implant removal or replacement due to a medical condition or complication.

Laparoscopic surgery can be a related procedure to a hysterectomy, allowing for a less invasive approach to remove the uterus.

The goal of a related procedure is to address any underlying conditions that may be contributing to a patient's symptoms, such as removing a fibroid during a hysterectomy.

A laparoscopic procedure can reduce recovery time and scarring compared to traditional open surgery.

In some cases, a related procedure may involve removing the ovaries or fallopian tubes during a hysterectomy to alleviate symptoms of endometriosis or ovarian cysts.

A related procedure can also involve repairing a bladder or ureter injury that occurred during the primary surgery.

If you've had breast implants, you might be wondering what happens if they become faulty. Well, insurance companies can cover the removal of faulty implants if it's deemed medically necessary.

Implant rupture is a serious issue, and insurance companies will cover removal if it happens. Severe capsular contracture is another condition that may require removal, and insurance will likely cover it.

Infection and chronic breast pain are also valid reasons for insurance to cover removal. And, unfortunately, breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare but serious condition that insurance will cover removal for.

Here are some specific reasons that may warrant insurance coverage for breast implant removal:

Keep in mind that insurance coverage for breast implant removal or replacement is not guaranteed, especially if the primary surgery was for cosmetic purposes.