Will insurance cover breast reduction w/lift if I have implants?

Insurance companies see things through a very narrow lens. You did not have implants placed in 2016 to correct for mastectomy or congenital deformity, and so they consider it cosmetic. The only sequela from breast augmentation they are willing to pay for is capsular contracture, and the surgery would be explantation. A surgeon can bill for that and still perform re-augmentation and breast lift, but that you would pay for. To complicate matters worse, your insurance plan has potential rules and regulations regarding how much or even if they will reimburse your surgeon for explantation and capsulectomy. Start this process by calling your insurance company and finding out about explantation for capsular contracture after cosmetic breast augmentation.

You have multiple options that may work for you. Some companies will pay for implant removal only if there are issues with the implants. If your natural breast tissue needs a formal reduction, typically defined as about 500g or more of tissue (about 1lb) per breast, insurance will cover a formal breast reduction (and lift) at the time of explant. However, if your implants are otherwise intact and your breast tissue is relatively minimal, it is likely that you will need to pay for the procedure out of pocket.

Thanks for your question! It is pretty unlikely that your insurance would come into play here. Most insurance companies would consider this cosmetic in nature. I would suggest calling your insurance company and seeing what they say. Good luck!

Hi,

Thank you for the question.

Based on what you are describing, it does sound that you have large/heavy breasts causing physical symptoms, and breast reduction may be an option for you. However, it is difficult to tell without seeing the photos and/or in person consultation.

During breast reduction surgery, excess breast tissue is removed, the breast is lifted and nipple/areola is typically made smaller. It is easiest to think of breast reduction as including the breast lift.

Schnur Sliding Scale is a scale used by many insurance companies as a guideline for how much breast tissue should be removed in order to improve your physical symptoms. In addition, most insurances in order to approve the surgery, will require for 2-3 letters of medical necessity (from your chiropractor, primary doctor, OBGYN, Dermatologist, etc) demonstrating that your physical symptoms due to large breasts are not improving with conservative management.

Breast implant removal is typically considered cosmetic in nature and is not covered by insurance. But breast reduction surgery is typically covered by insurance.

I suggest that you seek an in person consultation with a Board-Certified Plastic Surgeon specializing in Breast Reduction surgeries to further discuss your options, specific techniques, concerns and expectations. Make sure you specifically look at before and after pictures of real patients who have had this surgery performed by your surgeon and evaluate their results.
I hope this helps.
Best regards, Dr. Karanetz

Dr. Irena Karanetz
Breast Fellowship-Trained
Board Certified Plastic Surgeon

In most cases insurance companies do not deem implant removal as medically necessary and therefore do not provide coverage. You can call your insurance company for clarification, but this is typically considered cosmetic.

Some insurance companies will cover the cost of implant removal and capsules but nothing beyond that. You should speak to your insurance to find out but they are often vague about committing until you’ve seen the surgeon

Insurance companies will not cover reductions by removing implants. They will deem this cosmetic and it will be your responsibility financially. Unfortunately, you have not provided photographs or told us your bra size. However, the technique I recommend is explantation and lift using The Bellesoma Method. The implants are removed, your breast tissue is reshaped creating upper pole fullness, elevated higher on the chest wall and more medial to increase your cleavage. Vertical scars are avoided, nipple sensation (in 95%) and the ability to breast feed are maintained if not injured during your previous surgery. Later, fat transfers can be performed if additional volume is desired.

Best Wishes,

Gary Horndeski, M.D.

No, insurance does not cover anything with implants unless it is for reconstruction after a mastectomy. Exchanging implants for ones smaller is not considered a reduction. A reduction is a partial mastectomy that removes excess breast tissue and skin.

Dear Rdy4rnd2,
Although health insurance carriers vary in their requirements for coverage of breast reduction, I don't know of any that would consider breast implant removal as a qualification. However, pretty much all of the breast implant manufacturers have warranties of differing levels (dependent on whether you purchased a warranty upgrade) on their implants for capsular contracture that might help defray your costs. You can check with your implant manufacturer. Or see an American Board of Plastic Surgery board certified plastic surgeon for guidance. Good luck!

Medical insurance will not consider removing implants as a breast reduction.
Since you chose to have implants, it’s not something that is considered a medical issue.
Capsular contractions are however, considered a medical problem and treatment for capsular contractions, including removal of the implants is usually covered by medical insurance.
I don’t think you need a reduction if you had implants.
If you want to remove your implants, then that would be covered by medical insurance and so would be removing the capsular contraction.
I suggest you follow up with the plastic surgeon who did your augmentation or simply consult with other plastic surgeons in your community.
You may want to confirm that the surgeon is willing to accept insurance reimbursement.
Many plastic surgeons are simply not willing to accept medical insurance reimbursement because the payments are Insufficient to cover the expenses to run an office.
Many plastic surgeons do take medical insurance and it shouldn’t be that difficult to find someone who does.
You can always look up who does breast cancer reconstruction in your community and consult with plastic surgeons who do a lot of breast cancer reconstruction.
That type of work is usually based on medical insurance and those doctors typically have a lot of breast surgery experience.
If you’re having complications due to breast implants and medical insurance, most likely will cover the removal of your implants and capsular contraction. there may still be copayments and deductibles.
You can always contact your medical insurance provider to find out exactly what is covered and what is not covered
I think you’ll find it easier to have a plastic surgeon working with you when it comes to getting authorization for these procedures.
Best,
Mats Hagstrom MD