Explant surgery has been gaining popularity over the past year—with a nearly 10% jump in breast implant removals performed in the U.S. between 2019 and 2020, according to the American Society of Plastic Surgeons—and more and more celebrities opening up about why they got the procedure.
Breast implant removal can stem from a complication such as capsular contracture, seemingly related health issues like breast implant illness (BII), or just personal preference. And while many breast implants come with a warranty—for example, all four FDA-approved breast implant brands will cover the removal (and replacement) of implants for certain conditions within a given time period—your reason for explant surgery may not qualify. Or your warranty might have expired.
The next best thing, in that case, is to seek out insurance coverage, since implant removal surgery isn’t cheap; according to RealSelf members, it clocks in at an average cost of $5,050 (and that doesn’t cover implant replacement, fat transfer, or a breast lift—procedures patients often want in tandem with removal). But as with all things related to health insurance, doing so can be complicated and, oftentimes, discouraging. Here, what to keep in mind if you’re seeking insurance coverage to help pay for breast implant removal surgery.
1. You must have a diagnosis recognized by the medical community
Capsular contracture
If you’re looking for a guarantee in coverage, only two conditions really qualify, says Beverly Hills, California, board-certified plastic surgeon Dr. Kelly Killeen. “In general, your explant can be covered if you have a Baker IV, or the most severe form of capsular contracture, or a ruptured silicone implant,” she says.
Capsular contracture is one of the best-known complications of breast augmentation. “Anytime you put a foreign object in the body, your body recognizes it as foreign and walls it off with a scar-tissue sack,” says Dr. Killeen. “That’s what we call the capsule.” Typically, this capsule is soft and simply surrounds the “object” in question. But it can occasionally become thickened and abnormal.
There are four levels of contracture, ranging from mild (Baker I) to severe (Baker IV). The grading, says New York City board-certified plastic surgeon Dr. Irena Karanetz, is related to the scar tissue formation around implants. “It can tighten and distort the implant and cause pain,” she explains. While a Baker III might be covered, depending on the plan and insurer, explantation to resolve Baker IV contracture is almost always paid for by insurance.
Rupture
Rupture is another recognized condition for explant surgery. “Silicone breast implants have a silicone shell, and then the internal silicone is kind of a thick, cohesive glob,” says Dr. Killeen. “A rupture is when the sack around the implant breaks and that internal silicone comes in contact with body tissues.” This can also lead to pain and swelling. And the longer you have your implants, the more likely it becomes. “Every year, there’s a tiny increase in the risk of rupture,” says Dr. Karanetz.
Seroma
Finally, if there’s fluid around the implant, known as a seroma, that could be an indicator of a rare cancer called associated anaplastic large-cell lymphoma (BIA-ALCL)—the correlation of which led to an FDA recall in 2019. Because of this, “fluid around the implant prompts more workup,” says Dr. Karanetz. “The fluid is usually aspirated or drained. Then we look at the cells and the fluid, to make sure it’s not a lymphoma.”
What’s not covered?
Breast implant illness (BII), which is defined by a sprawling constellation of systemic symptoms. “Typically, it’s women who’ve had implants placed for either cosmetic or reconstructive reasons,” says Dr. Karanetz. “Then they have a variety of symptoms, such as fatigue, brain fog, joint and muscle pain, hair loss, weight changes, anxiety, and depression.”
However, BII is not considered an official medical diagnosis, and there’s no testing available to make it one. In other words, Dr. Karanetz explains, “there is nothing specific for insurance companies to confirm.” (Compare it to the above cases, which require either an imaging test, such as an MRI or ultrasound, or a physical exam.)
The symptoms may be real to patients, but without testing, it’s hard to prove the correlation between the implants and the illness to insurers—and if there’s one thing insurers insist on when shelling out for treatment, it’s proof. To change that, BII advocates are calling for an ICD-9 code for BII, which would classify it as a recognized medical diagnosis; but as Dr. Killeen points out, that doesn’t mean that the CPT code, which indicates the corresponding treatment for insurers, will even be covered.
This can be hard on patients and surgeons alike. “By the time they make it to my office, they’ve seen 10 different doctors [and] had a million tests,and everything’s negative—and they’re at their wits’ end,” says Dr. Killeen. But any stories about insurers covering explant surgery due to BII with certain tests and providers just aren’t true. “You’ll have all kinds of magical stories of people who somehow thought it was covered, but it’s just not reality,” she says. “I work with all different insurances, and it is just not covered unless you meet criteria.” This is the case despite research showing that implant removal may indeed alleviate BII symptoms. For example, a recent study in Plastic and Reconstructive Surgery concluded that breast implant removal via a capsulectomy can lead to high patient satisfaction among BII patients.
Ultimately, says New York City board-certified plastic surgeon Dr. David Shafer, it comes down to the reason for removal. “If it’s associated with a medical condition, insurance companies would have a hard time justifying not covering it,” he says.
2. You need imaging or exams to prove the diagnosis
Addressing your breast implants might not be as simple as just scheduling an appointment with the plastic surgeon who did the breast augmentation. “Depending on the patient’s insurance, they may see an OB-GYN, a general surgeon, or a primary doctor first,” says Dr. Karanetz. “The next step would be seeing a specialist, such as a plastic surgeon, getting evaluated and undergoing a physical exam, to see if there is anything wrong with implants.”
If your surgeon does suspect a complication, they may send you to get imaging. While you need only a physical exam for diagnosis of capsular contracture—for which photos will usually suffice—rupture requires diagnostic imaging. That can cause some issues with insurers. “The insurance company will not necessarily pay for the MRI, and the MRI can cost a couple thousand dollars,” says Diana Zuckerman, president of the National Center for Health Research, a nonprofit that helps consumers navigate their explant options. ”So that’s a bit of a catch-22.”
In some cases, you may need to do an ultrasound first, since these tend to be less expensive for insurers than MRIs. “The most sensitive and specific diagnostic imaging tool is MRI,” says Dr. Karanetz. “Sometimes you have to jump through hoops and get approvals and authorizations to get the MRI done—but it’s the gold standard.”
3. You need to stay in communication with your insurance company
Even if you believe your complication might be covered, double-checking with your insurer is still a good idea, to avoid any bills down the road. Dr. Killeen recommends getting the CPT codes for your treatment from your surgeon. Then “call your insurer and ask, ‘What do you pay for? What is your usual and customary payment for these CPT codes?’” she suggests. “Depending on your plan, they usually pay some percentage of that for out-of-network providers. For in-network providers, there’s a negotiated rate.”
The amount of coverage can vary, depending on your plan and subplan. “Typically, we are able to get full coverage for implant removal and capsulectomy, if needed, with insurance, if there is a rupture and or capsule contracture,” says Dr. Karanetz. Dr. Killeen, meanwhile, has found that payments can be all over the map, with some patients receiving a few hundred dollars and others being reimbursed thousands.
One of the insurers that tends to be more reasonable is Medicare, according to Zuckerman. “The good news about Medicare is, it’s pretty good about believing women and being willing to pay for explant surgery,” she explains. “The bad news is, it doesn’t pay a lot for that surgery.” As a result, you might have to do some homework to find a surgeon who’s willing to accept Medicare payment, since it’s generally less than what private insurers might offer (but again, it might not be offered at all).
It’s also a good idea to do a close read of the specifics of your plan. “Some policies specifically exclude any complication from cosmetic surgery, so it’s important to read and understand your policy,” he notes. In that case, even if you did have a diagnosable medical condition like capsular contracture, insurers could still be off the hook for the cost of implant removal.
Also worth keeping in mind: you may also need additional procedures, since once the implant is removed, patients are left with flat tissue that droops or sags. A breast lift is one common option, says Dr. Karanetz, but there are other alternatives to choose from. “For some patients, we remove the implants and replace them with fat grafting to add volume,” says Dr. Shafer. “For others, we remove the implants and replace them with a different size or shape [of] implant.” That, of course, is almost always paid out of pocket.
Finally, don’t give up if you don’t get the answer you want. “Insurance companies can be very difficult, as it seems their first response is to deny coverage and hope that the patient gives up,” says Shafer. “I have found that the most persistent patients have the best results with getting insurance coverage.” While it doesn’t always work, you might be surprised by what you get with enough tenacity.
