Does Medicare Pay for Breast Implant Removal?

Medicare is a federal health insurance program providing coverage for millions of Americans, primarily those aged 65 or older, and some younger people with disabilities. Understanding Medicare coverage can be complex, especially for procedures like breast implant removal. This article clarifies when and how Medicare might cover the costs associated with breast implant removal.

Understanding Medicare Coverage

Medicare is structured into several parts, each covering different types of healthcare services. Part A, known as Hospital Insurance, generally covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. Part B, or Medical Insurance, covers certain doctors’ services, outpatient care, medical supplies, and preventive services. Medicare Part C, also called Medicare Advantage, is an alternative to Original Medicare (Parts A and B) offered by private companies approved by Medicare. These plans must cover everything Original Medicare covers and often include additional benefits. Part D provides prescription drug coverage, which is separate from surgical procedure coverage.

Conditions for Breast Implant Removal Coverage

Medicare generally does not cover cosmetic procedures, including breast implant removal for purely aesthetic reasons. However, if the removal is deemed medically necessary by a healthcare provider, Medicare may cover part or all of the costs. The distinction between cosmetic and medically necessary is crucial for coverage.

Medical necessity typically arises from complications or health issues directly attributable to the implants. These conditions can include:
Rupture or leakage of the implant, which may cause symptoms or require intervention.
Severe capsular contracture, where scar tissue tightens around the implant, causing significant pain, disfigurement, or interfering with daily activities.
Infection around the implant site or an inflammatory reaction.
Obstruction of cancer detection during mammography or interference with cancer treatment.
Conditions like siliconoma or granuloma, or persistent pain and symptoms directly linked to the implants.

Steps for Coverage Approval

Securing Medicare coverage for breast implant removal begins with a thorough consultation with a qualified physician. The physician must diagnose the medical necessity for the procedure and document it extensively in the patient’s medical records. This documentation is crucial for supporting any claim submitted to Medicare.

The physician’s office plays a significant role by using appropriate diagnostic and procedural codes when submitting claims. These codes, such as ICD-10 for diagnoses and CPT for procedures, communicate the medical necessity to Medicare. Their correct application is vital for successful processing.

Prior authorization may be required by Medicare or a specific Medicare Advantage plan before the procedure. Patients or their providers should confirm this requirement and obtain authorization if necessary. Gathering all relevant medical records and physician statements detailing the qualifying medical condition and the necessity of the removal will strengthen the case for coverage.

Costs and What to Do if Denied

Even when Medicare covers breast implant removal, beneficiaries are typically responsible for out-of-pocket costs. For instance, under Medicare Part B, after meeting the annual deductible ($257 in 2025), beneficiaries are generally responsible for 20% of the Medicare-approved amount for services. There is no annual limit on these out-of-pocket costs unless the beneficiary has supplemental coverage.

Medicare Supplement (Medigap) plans or Medicare Advantage (Part C) plans can help cover these financial responsibilities. Medigap policies are sold by private carriers to help pay for costs not covered by Original Medicare, such as deductibles and coinsurance. Medicare Advantage plans may have different cost-sharing structures, often including an out-of-pocket maximum.

If Medicare initially denies coverage, beneficiaries have the right to appeal the decision. The Medicare appeals process typically involves five levels:
Redetermination
Reconsideration
Administrative Law Judge (ALJ) hearing
Medicare Appeals Council (MAC) review
Judicial review in federal court

It is important to act promptly, as appeals often have specific deadlines, such as filing a redetermination request within 120 days of receiving the denial notice. Thorough documentation and supporting evidence from the physician are important throughout this appeals process.