Will Aetna insurance cover implant removal? I am willing to travel as far as NYC.

Question

I have looked into having my implants removed because of capsular contracture. I know if I have baker grade 3 or 4 insurance will pay for it, it might be a fight but they will pay for it. I am starting to have sharp pains, and I've lost nipple sensation the pain takes my breath away. I need and want a doctor to help get these out, and put new under the muscle implants in with a lift. I know insurance will not pay for all of it BUT it would help a great deal towards the big picture.

Larry S. Nichter, MD, MS, FACS · Answer

Unfortunately, each insurance company has their own criteria. Large breasts (macromastia) or breast hypertrophy can occur in a variety of conditions (family trait, post pregnancy, excessive adolescent growth). In general when the excessive breast size causes functional problems, insurance will generally pay for the operation if more than 400 – 500 grams are removed from each breast dependent on your individual insurance company requirements. These problems may include neck pain, back or shoulder pain, hygiene difficulty, and breast pain. Other problems which are less likely to be covered by insurance include skin irritation, skeletal deformity, breathing problems, psychological/emotional problems, and interference with normal daily activities. Pre-authorization by the insurance company is required prior to surgery, and the process takes approximately one month. Each insurance policy has different guidelines and exclusions.This procedure is commonly covered by insurance through insurance criteria are becoming more and more restrictive. Although we do not accept insurance, our staff will assist you in obtaining pre-authorization so that you can attempt to be reimbursed for out of pocket expenses

Mariam Awada, MD, FACS · Answer

Please consider getting evaluated by a PS who accepts your insurance and performs the procedure.  You may need a referral so inquire with them if that is the case and get one so you can see your PS.  After a thorough history and physical they will document things and send it with your photos for approval by your insurance.

John LoMonaco, MD, FACS · Answer

The current AETNA policy will consider and review Grade III and higher cases and may cover removal. My experience has been mixed but it may be worth a try.  I might suggest you select your surgeon based on their breast lift experience and results, as this more than anything else will determine your results.

Tom J. Pousti, MD · Answer

I am sorry to hear about the complication you are experiencing. Unfortunately, online consultants will not be able to help with predictions whether a specific insurance company will help with expenses; ultimately, you will be best off contacting the insurance company directly or with the help of your plastic surgeon. It will be important that you select your plastic surgeon carefully; make sure that he/she has significant experience helping patients with this type of revisionary breast surgery.  You may find the attached link, demonstrating similar cases helpful to you as you learn more. Best wishes for an outcome that you will be pleased with long-term.

Bernard Kopchinski, MD, FACS · Answer

Thank you for your question. In my experience Aetna does not cover implant removal if the original surgery was cosmetic in nature. I would recommend calling Aetna directly to verify. A link to Aetna's Medical Policy for Implant Removal can also be found online. I hope this information helps.

Will Aetna insurance cover implant removal? I am willing to travel as far as NYC.

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