Though insurance companies don’t generally provide coverage for cosmetic procedures, certain reconstructive surgeries may be eligible for coverage. If you have had breast implants placed in the past for cosmetic reasons, some insurances may exclude your implant removal surgery even if you need to have them removed for medical (rather than aesthetic) reasons. Below, we’ve prepared a list of common questions and answers about explant surgery insurance to help you understand the details of the coverage process.
When Does Insurance Cover Explant Surgery?
First, it’s important to understand that coverage for explant surgery varies from provider to provider. You will therefore need to independently research the level of coverage offered by your individual provider for breast implant removal. When your policy does not clearly outline an exclusion for complications arising from an original cosmetic augmentation surgery, certain criteria would need to be met:
- She has severe (grade 4) capsular contracture. Capsular contracture is a hardening of the tissue around breast implants. It can cause chronic pain, as well as cosmetic problems.
- Her breast implants have ruptured. A leaking silicone gel implant is considered an urgent medical issue. Ruptured implants can cause irritation, infection, inflammation, and other dangerous symptoms. Breast implant removal is considered the safest way to remove a ruptured implant because the entire capsule around the implant is removed as one whole, undisturbed unit. This prevents silicone gel from entering the body and causing ongoing illness.
- The patient’s breast implants are harming her health. If your doctor believes that your implants are causing breast implant illness or damaging healthy breast tissue, your insurance carrier may cover your explant surgery even if your implants have not ruptured. Note that if you had implants placed after having a mastectomy and your doctor believes they’re making you sick, your insurance carrier is obligated by law to cover your explant procedure.
What Will I Need to Secure Coverage?
To be considered for coverage, you will need to provide supporting evidence that your capsular contraction is causing your breast pain. A letter of medical necessity from your physician will be required along with:
- MD office notes and exam findings relative to your case (From all previous treating physicians)
- Any information you feel would support your request
- Reports from Mammograms, Ultrasounds, MRIs, CT, and other laboratory/imaging studies obtained relevant to your request
- Previously tried treatments and medications
As a courtesy to our patients, once you provide us with the necessary documentation we can then submit your request for predetermination/prior-authorization.
Before you proceed with treatment, you should also verify that Dr. Mussat (National Provider Identification: 1194935262) is an “In-Network” provider with your insurance carrier. An In-Network provider is a physician who has signed an agreement with your insurance carrier to accept a specified dollar amount for his or her services. This agreement ensures that the patient does not have to pay any unexpected fees (because her carrier has already agreed to cover all applicable fees).
How Much of My Procedure Will be Covered by Insurance?
How much you’ll need to pay for your explant surgery will depend on the following factors:
Have you already met your deductible this year?
A deductible is an amount a patient is obligated to pay for her medical expenses each year before insurance will begin covering costs. If you have not yet paid your deductible in full, you will have to pay what you owe before your insurance provider begins contributing to the cost of your explant surgery.
What is your co-pay fee?
A co-pay fee is a fixed amount that insured individuals pay each time they use the services of a medical professional. You will need to pay this fee when you have explant surgery, even if you have met your deductible for the year.
Do you have co-insurance?
Co-insurance is a type of insurance plan that splits the cost of care between the patient and the insurance provider. Under a typical “80/20” split, for example, the insurance provider pays 80% of the patient’s medical costs and the patient pays the remaining 20%.
What is your out of pocket maximum?
Most co-insurance plans have what is known as an “out of pocket maximum.” This is the maximum amount a patient can expect to pay per year for medical expenses (after her deductible has been paid). For example, if your out of pocket maximum is $1000, you will pay $1000 of the 20% you owe for your procedure. Once you have hit this limit, your insurance company will begin covering 100% of the costs.
Will My Follow-Up Care Be Covered?
Most insurance carriers allow patients to receive follow-up care for 90 days after their procedure. This is called a “global period.” Care beyond this period typically will not be covered. Insurance carriers also generally do not cover the cost of subsequent revision surgeries. (E.g., if you wish to have scar revision performed a year after your procedure, you will need to pay for it out of pocket.)
What Should I Do if My Insurance Provider Doesn’t Cover Explant Surgery?
If your insurance provider does not cover the cost of breast implant removal, you should ask Dr. Mussat about alternative financing options. Dr. Mussat can help you secure affordable, convenient, and confidential financing through American Healthcare Lending.
Breast Implant Removal in Chicago: We’re Here to Help
Dr. Florence Mussat is committed to helping her patients access care. If you have any further questions about insurance coverage, or you wish to proceed with breast implant removal, feel free to contact her Chicago plastic surgery practice for more information.