Will Health Insurance Pay for My Breast Revision Surgery? (Part 2)
In part one of this article we discussed how some (not all) insurance companies may cover breast removal / revision surgery if the surgery meets their definition of “medically necessary.” In part two we discuss how a patient typically must “prove” medical necessity in order to obtain insurance coverage for breast revision surgery.
They type of medical evidence that the health insurance company will need to allow coverage based on medical necessity will depend upon the reason for seeking the breast implant removal and replacement.
Health Insurance Coverage for Breast Rupture Revision Surgery
If a woman’s saline or silicone breast implants are ruptured, the insurance company will need proof.
Generally MRIs are the best way to prove breast implant ruptures to the insurance company. However, the insurance company may also accept ultrasounds or mammograms. Remember, though, mammograms should be avoided whenever possible, as the pressure from them can also cause ruptures or leaks.
Health Insurance Coverage for Breast Capsular Contracture
Capsular contracture occurs when scar tissue tightens or hardens around breast implants, causing pain as well as a less natural appearance and feel. Capsular contracture can be mild and fell slightly uncomfortable – or be severe and cause debilitating pain.
Capsular contracture is rated on a scale of “Baker I” to “Baker IV.” While Baker I & Baker 2 are mild, Baker III or Baker IV causes breasts to be hard and/or painful.
Typically the insurance companies only consider Baker III and Baker IV level capsular contracture to be a medically necessary reason for breast implant removal or replacement.
Additionally, if a woman’s implants are causing extensive pain resulting from nerve damage and/or the weight of the breast implants, insurance companies will sometimes consider the breast revision surgery medically necessary.
What Breast Revision Surgery is NOT Considered “Medically Necessary”?
Sadly, many insurance companies do not consider autoimmune diseases or reactions to breast implants to be medically necessary. Similarly, physiological symptoms such as anxiety related to breast implants is generally not going to be considered a medically necessary reason for revision surgery.
And – just as with an original breast augmentation that is cosmetic in nature – insurance companies do not cover breast revision surgery for changing the size, shape or positioning of the breasts if the reasons are purely cosmetic.
How Do I Know if an Insurance Plan Covers Breast Revision?
To start understanding what revision surgery your health insurance covers, you can read through a copy of your actual insurance policy. Be careful not to rely on the short summary that is called a Summary of Benefits and Coverage. This will not be complete information.
Specific policy coverage regarding breast implants or breast revision will be in the “contract” that you signed when you signed up for health insurance coverage. Customers are entitled by law to receive a copy of their contract online or in the mail. So call the phone number on your insurance card and ask for a copy of your contract.
Remember, if your insurer does not cover the surgery you need, you can always consider switching to an insurer with better coverage during the next enrollment period. We also offer financing options for any procedures not covered by health insurance.
Troy Area’s Top Breast Revision Surgeon
Top plastic surgeon Dr. Ali has provided breast revision surgery for thousands of patients across Oakland County and the greater Detroit area, including: Birmingham, Bloomfield Hills, West Bloomfield, Troy, Southfield, and more.
Because of his expertise, high standard of care, and exceptional results in even the most difficult cases, he is the surgeon that other physicians refer their patients to for breast revision surgery. With his years of expertise, caring demeanor and modern techniques, Dr. Ali can fix almost any breast implant problem, including: implant rupture, asymmetry, capsular contracture, implant size change, and more.
No matter what problems or issues you are having with your breast implants, board certified breast revision surgeon Dr. Ali will listen to your concerns and help you find the solution.