When Will Health Insurance Pay for Implants?

Question

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.

Richard J. Bruneteau, MD · Answer

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.

Otto Joseph Placik, MD · Answer

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.

Scott C. Sattler, MD, FACS · Answer

The decision for insurance to pay for your breast implants will come down to a few important factors- 

	1. How 'good' your insurance coverage is 

	2. Can the augmentation on the smaller side be justified as 'reconstructive' rather than cosmetic

	3. Will the insurance pay for augmentation of the 'normal breast'

	I think you're going to have a hard time getting this quasi-cosmetic procedure approved by any insurance company. The companies I work with (Premera, Regence and BC)  would reject the claim.

	Breast reconstruction for cancer, on the other hand, is a federally mandated covered benefit. Insurance companies deny breast reconstruction claims at their peril.

Raj S. Ambay, MD · Answer

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.

Steven Wallach, MD · Answer

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

Olivia Hutchinson, MD · Answer

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.

C. Bob Basu, MD, MPH, FACS · Answer

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.

Darryl J. Blinski, MD · Answer

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

George Sanders, MD · Answer

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.

Shahin Javaheri, MD · Answer

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

When Will Health Insurance Pay for Implants?

Answers (14)

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