How to Get Insurance to Pay for Breast Implant Removal?

Navigating insurance coverage for breast implant removal can be challenging. While insurance providers typically do not cover purely cosmetic procedures, removal due to documented medical necessity often qualifies for coverage. Understanding the specific criteria and steps is essential for coverage.

Establishing Medical Necessity for Coverage

Insurance companies determine coverage for breast implant removal based on a clear medical necessity, rather than aesthetic concerns. This typically involves specific complications or conditions directly attributable to the implants. Common diagnoses that may warrant coverage include severe capsular contracture (hardening of the tissue capsule around the implant), implant rupture or deflation, chronic infections, significant pain, or nerve compression related to the implants.

Documentation of symptoms consistent with Breast Implant Illness (BII), when supported by objective medical findings and a physician’s assessment, can also be a basis for medical necessity. Insurance providers generally require objective evidence to confirm these conditions. Such evidence typically includes diagnostic imaging results, like an MRI or ultrasound report, confirming implant integrity or rupture. Pathology reports from prior biopsies or surgeries can also provide supporting evidence for issues like chronic inflammation.

A physician’s comprehensive clinical notes are also important, detailing the patient’s symptoms, their duration, and their impact on daily life. These notes should also outline any conservative treatments attempted and why they were unsuccessful.

Preparing Your Insurance Claim Package

Assembling a thorough claim package is a key step for insurance coverage. This package should include:

A detailed letter of medical necessity from your treating physician. This letter should clearly state your diagnosis, provide a comprehensive description of your symptoms, and explain how these conditions significantly impact your daily activities and overall health. It should also include the proposed Current Procedural Terminology (CPT) codes for the explantation surgery, such as 19328 for removal of an implant without capsulectomy or 19330 for removal with capsulectomy, and potentially 19371 for capsulectomy if performed separately.
Copies of all relevant diagnostic test results that support your medical necessity. This includes imaging reports, such as MRI or ultrasound scans, confirming implant rupture, severe capsular contracture, or other documented complications.
Any pathology reports related to prior biopsies or surgeries on the breasts.
Your complete medical history records, specifically those pertaining to your breast implants and the onset of your current symptoms.
A detailed surgical plan from your surgeon, outlining the specific procedures to be performed. This plan should align with the CPT codes provided and describe the necessity of each component of the surgery.
Your personal insurance policy details, including your member identification number and group number, as these are necessary for accurate claim processing.
Specific pre-authorization forms, which can typically be downloaded from your insurance provider’s website or obtained by contacting their member services department.

Submitting and Following Up on Your Claim

After gathering all necessary documentation, submit your pre-authorization request to your insurance provider. Many insurance companies offer an online portal for submitting requests, which often allows for direct upload of documents and provides immediate confirmation of receipt. Alternatively, requests can be submitted via fax or mailed to the address specified on your insurance card or on the pre-authorization form. Retain copies of all submitted documents for your records, along with any confirmation numbers or tracking information.

After submission, you should receive a confirmation that your request has been received, often within a few business days. The typical review timeline for pre-authorization requests can vary significantly among insurance carriers, generally ranging from several days to a few weeks, sometimes extending up to 30 days for complex cases. During this period, track the status of your claim through your insurer’s online portal or by contacting their member services department directly.

The insurance company may contact you or your physician’s office with requests for additional information or clarification. Promptly responding to these requests is essential to prevent delays in the review process.

Appealing a Denied Claim

If your initial claim for breast implant removal is denied, understanding the specific reasons for the denial is the first step in the appeals process. Insurance companies are required to provide a detailed explanation for their decision, outlining why the claim was not approved. This explanation will guide your strategy for the internal appeal.

Most insurance plans offer an internal appeals process, which typically involves submitting a formal appeal letter along with additional supporting documentation. The appeal letter, often drafted by your surgeon or their office, should directly address the reasons for the denial, providing further medical justification and evidence. Additional documentation could include a more detailed medical opinion from your surgeon, results from new diagnostic tests, or relevant peer-reviewed medical literature supporting the medical necessity of the procedure for your specific condition.

Adhere to the deadlines for submitting an appeal, which are typically outlined in the denial letter and can range from 60 to 180 days from the date of the denial notice. If the internal appeal is unsuccessful, you may have the option to pursue an external review. This involves an independent third party reviewing your case and the insurer’s decision, providing a final layer of recourse.