Partial Insurance Coverage for Augmentation Problem?

Bi-lateral augmentation (hopefully surgeon was honest when he said they were saline,) 2/1982. They seemed to hold up well and I am now 57. Took a hard fall onto brick patio 4 mos. ago; CT for atlectasis/pneumonia showed "likely rupture" of R' implant. Both are likley ruptured as the last mammogram shows folds in each one. Will insurance cover the removal if done in outpatient hospital setting? No guarantees I know; but am hopeful and wonder how to approach BCBS. Thanks so much!

Doctor Answers 11

Insurance coverage

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The only breast surgery that insurance companies will cover are related to procedures for reconstruction after breast cancer.  Given your prior history of cosmetic breast augmentation, it is very very unlikely your insurance company will provide coverage for your implant removal.  But you can always call your carrier to find out...

Breast Implant Revision - Insurance Coverage

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Hi Queenie1953

The absolute answer to any question concerning insurance coverage for this, or any other procedure, is that it depends on the specifics of your insurance policy.  Each policy is different and there's no way to determine that in the abstract.  What you'll have to do is to go to a plastic surgeon, explain what the situation is, collect any outside reports of consultations and non-interventiional diagnostic tests you've had, and then have your plastic surgeon contact your insurance company to see what, if any, portions of your proposed surgery are "covered."  Then you can take it from there.

But that raises the next question:  if the insurance company says it's covered, will your plastic surgeon accept that amount as an adequate payment for the procedure?  Not always.  As insurance reimbursements have changed over the years, and deductibles and copays have risen, it's become that much more critical that you know in advance not just what will be "covered" but what payments will be made and what will be acceptable to the surgeon, the surgical facility, etc.  Unpleasant, perhaps, to have to do all of this, but there's not really much choice.

Finally, if I had to guess, I would think that relatively little of the necessary costs will be provided by the insurance company.  If you have clear medically-related symptoms as a result of what you have and what has happened, then the likelihood is greater.

I hope that this helps, and good luck,

Dr. E

Breast Implant Removal and Inusrance

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The only way to know if the removal of your deflated implants would be covered is is to contact your insurance provider and discuss your specific situation. Every Insurance company and every plan is different.   Best wishes!

Christine Sullivan, MD
Columbus Plastic Surgeon
4.5 out of 5 stars 35 reviews

Coverage by insurance

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Each insurance coverage is different in the way they handle patients with implants. You should contact your insurance company and ask them.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Implants problems covered by insurance

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The answer to this question is "sometimes."  Capsular contracture and implant rupture are the most common reasons for insurance to cover breast implant problems.  However, every plan is different and it also depends on whether or not your surgeon is in network or out of network.  This is worth a call to the office of your surgeon for guidance.

Jay Calvert, MD, FACS
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 52 reviews

Insurance Coverage of BreasT Implant Removal

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Insurance plans are not an all-you-can-eat menu; they are better described as a cafeteria dining where you pick the dishes you want (the services covered), you pay (your employer) pays for them and you get to eat (or get to be treated for) what you paid for. If YOUR policy does not cover medical services you may need or want, they are not obligated to pay for them.

When it comes to breast implants, the operation was cosmetic (IE not intended to save life or improve function) and as such the vast majority of insurers will not pay for any complications  or issues related to it. I never seen an insurer pay for implant exchange but occasionally they may pay for permanent implant removal. To find out read your brochure and then call them and see what benefits you have.

Dr. Peter Aldea

Peter A. Aldea, MD
Memphis Plastic Surgeon

Insurance Coverage of Implant Replacement

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The only occasion in which insurance will definitely cover the replacement of a ruptured implant is wheb the diagnosis of breast cancer is present.  Rarely insurance companies will cover removal, but not replacement, of silicone implants which were placed for cosmetic reasons and are ruptured.

John Whitt, MD (retired)
Louisville Plastic Surgeon

Insurance coverage for possible implant rupture?

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If you had saline implants placed diagnosis of a rupture is usually fairly easy as there would be a drastic change in volume. For silicone, this is not the case.

Regarding your question about insurance coverage for a possible rupture of breast implants placed for cosmetic reasons, this does vary quite widely among insurance companies. In some situations, a few may paritally cover this particularly if there was an associated capsular contracture or clear cut evidence of trauma. To better determine your situation, you would need to contact the insurance company and find out what if any their coverage is regarding breast implants placed for cosmetic reasons. I also strongly recommend that you obtain a consultation with a reputable board certified plastic surgeon in your area so he/she can obtain your history, examine you and then make recommendations.

Steven Turkeltaub, MD
Scottsdale Plastic Surgeon
4.7 out of 5 stars 33 reviews

Breast Implant Removal

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Sometimes breast implant REMOVAL can be covered by insurance. Often, however, they will request documentation that shows the implant or breast capsule (normal scar tissue that forms around an implant) is causing pain or irritation from contracture. A physical exam may help in this. They do not often cover implant removal just for rupture. 

Insurance coverage

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I think it's pretty unlikely that insurance will cover any part of your surgery.  They will sometimes cover removal of ruptured of silicone implants or in the case of painful capsular contracture.  The best thing you could do is to have your surgeon try to get a preauthorization from your insurance company and see what they say.  Best of luck!

David S. Rosenberg, MD
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 11 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.