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When Will Health Insurance Pay for Implants?

I have small breasts (barely A) and many fibroadenomas in one of them that are growing and I keep finding more. I will need to have them removed at some point and I'm wondering if, because it is a medical necessity, my health insurance will pay for me to get implants afterwards, as I will likely end up with almost no breast on one side.

Doctor Answers 14

September 18th, 2015

Coverage By Insurance Is Rare

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Unfortunately, most insurance companies only cover the expense of treating breast asymmetry when it’s associated with breast cancer.They view this type of procedure as purely cosmetic.Rarely, insurance carriers will cover the expense of these procedures when they’re associated with functional impairment.This usually requires going through the prior authorization process to establish medical necessity.This is usually always unsuccessful.
Richard J. Bruneteau, MD
July 17th, 2013

Insurance companies and breast implant coverage

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By law, insurance companies must pay for implants used in breast reconstruction associated with cancer.  Everything else will be considered cosmetic and not be covered. Every insurance is different with the exception that they profit by not paying for health care services. There is a perverse incentive to collect premiums from consumers and not pay for care. You have to be your strongest advocate for your health. As a consumer, call your insurance company and make your case. I bet you doctor will arm you with all the medical documentation.  

Raj S. Ambay, MD
February 6th, 2011

Breast implant coverage

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If you have mastectomies for prophylaxis you are a candidate for reconstruction and your insurance company should cover that.

Learn more: http://www.stevenwallachmd.com

Steven Wallach, MD

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

January 24th, 2011

Insurance coverage of breast implants

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Health insurance companies usually only cover medical and surgical procedures which they deem to be "medically necessary". It is very unlikely that an insurance company will cover breast implants except in cases of reconstruction after cancer surgery. However, your surgeon may request pre-determination prior to your surgery by submitting the required documentation to the insurance company.

Olivia Hutchinson, MD
New York Plastic Surgeon

January 23rd, 2011

Insurance Coverage

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Breast Implants are covered if they are being used as part of a reconstruction after breast cancer or mastectomy.  Insurance companies generally do not cover other procedure as they deem them cosmetic surgery.   

Learn more: http://www.basuplasticsurgery.com/houston-breast-surgery/breast-augmentation/

C. Bob Basu, MD, FACS
January 23rd, 2011

When Will Health Insurance Pay for Implants?

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You nee to write/call/ fax your insurance company to see if the certification/qualifications/predeterminations are or include implants for fibroadenoma removal. Also have a boarded PS write a letter for you. It just may help but I doubt it. But worth the try. From MIAMI DR. Darryl J. Blinski

Darryl J. Blinski, MD
January 22nd, 2011

$ave Your Money

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It is difficult to predict how your insurance company will decide in this matter. It depends in large part on how your breasts look after the removal of the fibroadenomas. If there is a great deal of difference between the two sides, the chance of insurance coverage is greater. Coverage of breast augmentation also will depend on what the state of health care is in our country when you try to have your surgery. My best advice: Save your money to pay for breast augmentation yourself.

George Sanders, MD

George Sanders, MD
Los Angeles Plastic Surgeon
4.9 out of 5 stars 13 reviews

January 21st, 2011

Submit insurance letter with supporting photographs documenting deformity

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It is most probable that implants will NOT be covered for benign disease. However, if you have a compelling story and dramatic differences, consider having your general surgeon compose a letter with supporting photographs requesting a predetermination of benefits. Perhaps the reviewer would be sympathetic to your cause (unlikely) but it may be worth a chance if the difference is as pronounced as you state.

Learn more: http://www.bodysculptor.com/

Otto Joseph Placik, MD

Otto Joseph Placik, MD
Chicago Plastic Surgeon
4.9 out of 5 stars 86 reviews

January 21st, 2011

Breast implants

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Breast implants are covered by insurance mainly in the case of breast reconstruction in cases of breast cancer. 

Shahin Javaheri, MD

Shahin Javaheri, MD
San Francisco Plastic Surgeon
4.4 out of 5 stars 6 reviews

January 21st, 2011

Breast implants are covered for breast reconstruction and?

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Breast implant are covered by insurance for breast reconstruction, but also depending on the policy and review, implant may also be allowed for cases where 'medical necessity' has been established. We have had implant coverage in young women with developmental asymmetry including Polands's syndrome, and for rehabilitation after multiple breast biopsies and for individuals who have a simple mastectomy because they are breast cancer gene carriers. It never hurts to begin with a predetermination request to your carrier.

Best of luck,

peterejohnsonmd

Learn more: http://www.peterejohnsonmd.com

Peter E. Johnson, MD

Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 44 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.