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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

Coverage By Insurance Is Rare

September 18th, 2015
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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

Insurance companies and breast implant coverage

July 17th, 2013
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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

Breast implant coverage

February 6th, 2011
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If you have mastectomies for prophylaxis you are a candidate for reconstruction and your insurance company should cover that.

Web reference: http://www.stevenwallachmd.com

Steven Wallach, MD

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 23 reviews

Insurance coverage of breast implants

January 24th, 2011
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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

Olivia Hutchinson, MD
New York Plastic Surgeon
5.0 out of 5 stars 8 reviews

Insurance Coverage

January 23rd, 2011
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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.   

Web reference: http://www.basuplasticsurgery.com/houston-breast-surgery/breast-augmentation/

C. Bob Basu, MD, FACS

When Will Health Insurance Pay for Implants?

January 23rd, 2011
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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

$ave Your Money

January 22nd, 2011
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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 12 reviews

Submit insurance letter with supporting photographs documenting deformity

January 21st, 2011
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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.

Web reference: http://www.bodysculptor.com/

Otto Joseph Placik, MD

Otto Joseph Placik, MD
Chicago Plastic Surgeon
4.9 out of 5 stars 72 reviews

Breast implants

January 21st, 2011
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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
4.3 out of 5 stars 4 reviews

Breast implants are covered for breast reconstruction and?

January 21st, 2011
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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

Web reference: http://www.peterejohnsonmd.com

Peter E. Johnson, MD

Peter E. Johnson, MD
Chicago Plastic Surgeon
4.1 out of 5 stars 39 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.