Explants May Be Covered by Insurance

Whether you are under a national, provincial, state or private health insurance plan explants may be covered by insurance for what they  deem to be the accepted medical reasons to explant which generally are rupture, significant capsular contracture, chronic pain, infection/tissue necrosis that won’t go away and BIA-ALCL which is a cancer of the immune system caused by breast implants.  

Whatever your coverage, get a full copy of your health insurance policy and read why and how you may be covered for explant of breast implants which is usually found on the EOC – Evidence of Coverage page(s) of the policy.  Some policies will exclude covering explant for breast implants placed for cosmetic reasons and some may have inclusions for other reasons.  Some policies require pre-approval or they will not cover you even if you meet the accepted medical reasons to explant so be careful about obtaining pre-approval if necessary.  Reconstruction is not considered cosmetic and explanting reconstruction should be covered by health insurance policies.  Please note, health insurance policies usually do not cover for breast implant illness symptoms or autoimmune symptoms so avoid discussing these at medical appointments for obtaining insurance coverage as it may result in a denial.  

Many ladies are put off or denied in the initial application process but have success appealing so being persistent with insurance companies pays off.   

In the United States so far the following insurers are more likely to pay for explant: Blue Cross Blue Shield, Medicare, United Health Care, Aetna and Cigna.  Here is a helpful link for navigating insurance coverage in the U.S.: http://breastimplantinfo.org/insurance/

Procedure and Diagostic Codes for Explant
in North America

Procedure and Diagostic Codes for Explant in North America

Insurance Procedure Codes CPT for Explanting Breast Implants:
19328 – 50 Removal of intact mammary implant, the 50 is the modifier for Bilateral
19330 – 50  Removal of ruptured breast implant and implant contents, the 50 is the modifier for Bilateral
19370 – 50 Revision of capsule, partial capsulectomy, the 50 is the modifier for Bilateral 
19371 – 50   Removal of the implant and total capsulectomy, the 50 is the modifier for Bilateral
19380 – 50  Revision of reconstructed breast, the 50 is the modifier for Bilateral
11971 – 50 Removal of a tissue expander, the 50 is the modifier for Bilateral
01991 – Injection Pain Block
00402 – Anesthesia Thorax Region 
99205 – Facility Fee

Insurance Diagnostic Codes ICD10 for Explanting Breast Implants:
T85.49XA – Mechanical complication of breast prosthesis and implant
T85.79XA – Infection and inflammatory reaction due to other internal prosthetic devices, implants, grafts.
T85.848A – Pain due to internal prosthetic devices, implants and grafts.
T85.44XA – Contracture of Breast Prosthesis
T85.43XA – Rupture of Breast Prosthesis
N64.81 – Breast Ptosis
N64.4 – Mastodynia

If Surgeons Refuse to Assist you With Coverage - Advice from Another Breastie

If Surgeons Refuse to Assist you With Coverage:
Advice from Another Breastie

Hey Breasties!

I wanted to provide some info regarding insurance and some helpful tips that might lead in a direction of getting your upcoming surgeries partially covered, or for getting your already explant partially reimbursed. Please note I have Blue Cross/Blue Shield so I cant guarantee this info will work for all insurance providers. However, I come from a medical background as well as a medical filled family and we have gotten real good at dealing with insurances J also the key with insurance companies is: Keep on swimming. Meaning, don’t give up!

As we all know most of our Plastic Surgeons as well as Surgery Centers are not ‘in network’ providers… which is why we are paying out of pocket. Also they deem our explant as ‘elective or cosmetic’ so they don’t plan on covering us. So we must take matters into our own hands.

  1. You must get a good insurance agent on the phone! There are hundreds so if you aren’t getting anywhere with one; politely hang up, and call back! I promise you wont get the same agent. I speak English, so when I get someone from another country that I can’t understand well I ask to speak to an English-speaking agent in my zip code or city. This helps sooooo much!  In my experience local agents are very kind, patent, and willing to take the time.
  2. Explain the situation of your health, and tell them you need an urgent surgery as you are in a lot of pain due to your implants. Let them know that there are a few specialist that do this surgery, and the ones in your area are either booked too far out or do not specialize in the removal of all that is necessary. From here they are going to ask a ton of questions about the doctor and surgery center.  If you have this info then great!! If not tell them they can email you the form and you will send to the doctor’s office to fill out. If they fight you on this, ask for a supervisor. I had to speak with 3 agents before the 4th agent said, that’s no problem I’ll email you the form. P.s there were a few questions on this form and all can filled out by you, no need to send to PS.
  3. Address
  4. NPI number (this can be found on Google)
  5. Phone, fax, and Codes
  6. The form I received is called a “Medical Care Review” this is not a claim form. However if you have already explanted you will probably be receiving a claims form and adding all this info. You will also want to know the codes to use. (see codes attached) the first CPT code is for the explanation of explanting, the ICD-10 codes are to explain why. I used the 3rd ICD-10 code, as I know that pain rules over infection, or cosmetics, etc… (According to insurance rules, not my own opinion).  
  7. I sent this form back to my agent (same agent the entire time, they will walk you through the whole process). Once this is all completed and sent back, you wait.
  8. I then received a form that was to be sent to my doctor again for extra needed clarification.  It asked:
  9. What was reason for putting in implants? Cosmetic (For me)
  10. Type of implant being removed?
  11. Radiological reports (if applicable) I had none so wrote N/A
  12. Operative Reposts (if applicable) I had none so wrote N/A  ** Ladies who have explanted this is good place to put your operative notes.
  13. Once you send this back to agent then you are done, and wait for your review of Approval/Allowance.

Please join our Facebook group of over 150,000 women for support through your healing journey.

We look forward to your comments, feedback and personal stories about your symptoms due to breast implants. Please see the comment form below. Thank you.

This Post Has 98 Comments

  1. Lynn Roberts

    What if you’re on Medicaire and have supplemental insurance coverage? Cigna is my supplemental.

  2. Nathalie

    I am on invalidity with sunlife. Anyone can share with me how to proceed?

  3. SC

    Has anyone had Tricare Prime insurance and did they cover this type of procedure due to BII?

    1. Brandi F

      Did you find out of Prime will cover explant?

  4. Juniper

    I am in TX with BCBS of Alabama PPO (I work remote, my employer is in AL) and wondering if anyone else has had luck with BCBS-AL PPO? Are my odds better if I go to a doctor in Alabama or does it not matter? Thanks in advance

  5. TMT

    Anyone try to get a reimbursement from a US insurance company while doing the explant with a BII specialist in Mexico?

    1. Christie Canfield

      I have full Montana Medicaid as part of the Breast and Cervical Cancer program. I have been experiencing severe pain with my implants as well as many signs of BII. I am also worried about BIA-ALCL as my left implant is significantly more painful/tight, I’ve lost 10 pounds in 6months without even trying, and have extreme fatigue and ataxic events. Only after I mentioned possibly removing my implants as last resort plastic surgeon said I needed the best and referred me to the specialty center in New Orleans where I’d be covered since I have reconstruction due to cancer. Well, they don’t accept Medicaid if any form nor do many other surgeons I’ve called from the approved list. Her surgery coordinator called and said she does not have any other in-state suggestions for me. Said I was on my own and good luck.MT Medicaid says if my surgeon is not able to do the surgery, then she needs to make the referral and discuss insurance with the specialist . She is not willing to do this unfortunately. Absolutely no patient submittals are accepted with this program. I will contact my new local oncologist to see if there are any other suggestions they might have regarding any reciprocity with large institutions out of state. I tried to get onto my husbands Aetna plan but was told I would be committting a crime to try to gain another insurance plan already having Medicaid. (Which Medicaid said is not true) There would have to be an event that caused Medicaid to cancel my plan to allow me to get onto an Aetna plan . But even if that did occur, I would not be able obtain a policy since the enrollment is not until December for 2023 coverage. I feel like the life is slowly being sucked out of me here as I continue to run into brick walls . Meanwhile, if you have any comments/suggestions, I’d be most appreciative.

  6. Pat

    Does anyone know how to find the facility codes or the anesthesia codes?

  7. Cris Harper

    Does anyone know whether submitting claim before or after the procedure makes any difference? My doctor isn’t contracted with insurance and is not in network. He believes I should be able to be reimbursed but it will be my responsibility to seek reimbursement. Procedure is in about 2 months. Do I start attempting now or wait until it’s done? I have BCBS Ca HMO

    1. Stacey

      Same here. My doc doesn’t take insurance and he’s not in network. I explant on Monday. Please let me know if you find out any answers and I’ll do the same.

    2. JGoss

      My insurance company requires a prior authorization for this procedure. If I go out to a surgeon who take no insurance, it’s on me to get the prior authorization. If the surgeon takes insurance, but not my plan, their office should handle the prior authorization.

  8. Judy Goodwin Coyle

    I have Medicare with Cigna as a supplement. I am hoping for good results. I am trying to get the ball rolling on this…..

  9. Pamela

    Alice did you ever get procedure codes for facility and anesthesia? If so can you let me know? I have United Healthcare. Thanks in advance Pamela

    1. Linda Pearson

      When you say ruptured does this include saline implants?

  10. Sherry

    Hello ladies I am in Vancouver British Columbia and equitable life is my provider I’m wondering if anybody has had any luck with them covering the procedure thank you so much

  11. Jessica.

    Hi anyone from Australia have any luck with insurance getting an explant? I am currently in Mexico and can’t finance the explant. Back in 2016 I was having swelling I had all these years done & dr said they just needed a drain and that and explant wasn’t necessary. I wish I had fought it as iv been traveling since 2016 & they’ve been nothing but trouble – All the symptoms 😅

    1. TMT

      Did you ever get an answer? I’m about to explant in Guadalajara in a month bc I wanted a BII specialist after my primary care hospital did not really understand BII and is actually cheaper to go through Buenrostro than my care provider with insurance included (plus knocked off a year of waiting in desperation while going through the whole process of tests, physical therapy, ect to approve just the explant and not even capsulectomy/en-bloc and lift.

  12. amy bynum

    did you end up seeing dr straka and get insurance

  13. Shelley Marriott

    Anyone have Aetna insurance that covered explant and enbloc in Utah? Thanks Ladies.

    1. Joy Saghy

      I have Aetna, have you found out anything on coverage yet??

  14. Danielle

    Blue Shield of CA Access + paid for my explant and my surgeon accepted payment by BS. Initial request by surgeon denied, I requested peer to peer review with my PCP which won approval. Mine were 25 year old textured tear drop Allergen.

    1. Eunice

      Wouldn’t this be wonderful. I’m in So Cal and just starting the process. 2 months for mammogram but did get an MRI for mid November. Was your surgeon on the list?

    2. Melissa

      I have this same insurance. My PCP ordered an MRI to be done and put in a referral for me the see a plastic surgeon. (I had an MRI done in 2019, it showed silicone through out my breast but no rupture. very contradicting)

    3. Brandy McGinnis-Buller

      Hi , Danielle
      I also have BCBS – Florida is mine , I also have the exact type of implants except mine are 27 years old. I’m in process of trying to find a PS to do my surgery and I it would be extremely helpful if I could get insurance to pay for the surgery , can you tell me what codes you used and did you get a lift also and if so was that covered as well. The doctor I wish to use refuses to help at all with insurance. So that being said I don’t know if I would have to pay out of pocket and have bcbs pay me back or do I go about it another way. Any help would be appreciated.
      My Email is [email protected] or my face book is
      Brandy McGinnis-Buller , not sure how to receive messages back from this post. Thanks

      1. Stacy Hardwicke

        I’m in the same state and same insurance. Please update me if you receive information.

  15. Lisa Peterson

    I explanted in 2013 due to a slow leak that caused a severe rash, before it was realized that an Implant was leaking and deflating slowly. My surgery was done with LIDOCAINE and the Implants were removed while I was widenawake talking to the surgeon. My capsules were NOT removed. (I did not re-implant with another set.) Does anyone know how I would go about getting the capsules removed? Any help would be greatly appreciated. Thank you.

  16. Vicki

    I want to have the explant surgery. I am a cancer survivor, and can go on Medicare next month. I chose not to because I am still covered at my job. Does Medicare cover explant operations? Or would insurance be better? I’m new to this and no clue about Medicare! Thx

    1. Terri

      I believe Medicare does but I think you have to go to a doctor that accepts Medicare. Definitely start googling and get as much information as you can from the Medicare site

    2. Jen

      It will be approved by your insurance if you have a history of breast cancer

      1. Karen Granato

        All insurances? I had stage 0 breast cancer 20 years ago. Had a lumpectomy and went on Tamoxifen. My implants were 9 years old. I just had them removed in November 2021. I wonder if I can be reimbursed?

    3. Deborah

      I’m on Medicare as well. They gave me a list of “good ” PS in my area and told me it’s case by case and depends on what they find. It helps for your doctor to write up a medically necessary letter. I saw where someone wrote back after a denial of how sick she was before explant and how much better she was after and they paid. It was BCBS I believe.

  17. Robin

    Has anyone that has TXBCBS (Texas Blue Cross Blue Shield HMO) got them to cover explant? I’ve already met my deductible & my out of pocket for the year. So trying to explant this year!

    1. Cheryl

      I’m in the same boat BCBSTX as well but PPO.

      Let me know if you get any further information

      [email protected]

      1. Laura

        I have BCBSTX PPO too! I am curious if anyone has had any luck with them?

        1. Sibs

          My HR department told me to submit a Predetermination Request form to BCBSTX. I had my PS fill out his part and faxed it over today, 11/2/2021. So we’ll see what they say.

  18. Deborah

    There’s a kaiser doctor on the explant list in ga.

  19. Mv

    Does NJ health ( family care cover ex plant anyone know)

  20. Charlotte Cannon

    A lot of information which helps in making your decision and the best pathway to discover your choices.

  21. Martha

    I use to work in insurance and you file with the primary and then they forward to secondary but if the primary won’t cover then the secondary won’t either! Very frustrating! Good luck!

  22. Tiffany

    My insurance just approved my procedure next week, I have blue shield of CA.

    1. Kellie

      Hi Tiffany, can I ask you some questions re: blue shield of CA? please email if you get this reply! kelliequ at gmail dot com. Thank you!!

    2. Meghan

      Hi Tiffany! Would love to know if you found a surgeon in Cali that helped you accomplish that. I also have Blue Sheild of CA.

      Thank you in advance!

      1. Kim

        Me too please, if you can share infos. I’m in Irvine, near Newport. Also heard explants need to be done by a very very good experienced doctor.

        1. Jackie

          Hi! Go to Dr. Semira Bayati in Newport Beach!! Not only is she so comforting in believing us… but she does do beautiful work! I explanted 3 months ago with her

      2. Jill Solow

        When you say agent, do you mean someone that answers the 800 numbers or someone else? Sorry, I’m confused.

        1. Kimber C

          I’ve got the same question!

          1. Judy-Ann

            HI Kimber and Jill!
            Did you ever get an answer to your question? I am curious about what she meant by “agent” as well.
            thanks

    3. Sonia Molina

      Seriously? Was it hard to get? What did you say yoir reason was? I have Blueshield of Ca, had the saline implants for 10 years. I don’t know if me feeling fatigued and loss of memory is a symptom , but I know it’s time to take this toxic object out

    4. Janeen

      Tiffany I have Anthem Blue Cross Blue Shield so can you email how you got this done at [email protected]? Pleaseeeee

      1. Holly

        Janeen – emailing you ….. PLEASE AND THANK YOU!

    5. Elizabeth

      Hi Tiffany, please email how you got ins to cover and steps you took. Thank you in advance. Email to [email protected]

      1. Kimber

        Yes Tiffany, if you wouldn’t mind emailing me as well?
        I would greatly appreciate it.
        [email protected]

    6. Deborah

      How did you do that? 😊

    7. Jeanette Weimer

      Hi Tiffany, I to have BCBS Ca (PPO) Medicare supplement…
      Any info u can pass on would be greatly appreciated!
      What PS did u use!
      [email protected]

  23. Terri Schmidt

    Looks like a lot of women looking for Medicare to cover explant. Did any of you ladies make any headway in getting Medicare to cover your explant surgery? Many of us would love to know. I am having explant in June 2021.

    1. C Wise

      Did you get any more info on Medicare paying. I also have a supplemental with BC/BS in Georgia. Looking for info. Can’t afford unless Medicare pays. If medicare pays then secondary will pay remaining 20%.

  24. Terri Schmidt

    jeannie , I am 67 and would Medicare to cover my explant. Did you ever have any luck with getting Medicare to pay?

  25. Bobbi

    Hi Nicole,

    Would you recommend going out of state to a surgeon who will submit to insurance over doing this all yourself? I live in Michigan and none of the doctors submit to insurance for explant surgery. I have 3 possible locations in 3 bordering states that i was going to reach out to for possible full or partial coverage by insurance. Any insight would be appreciated.

    1. Nicole

      Hi Bobbi,
      Ladies of the facebook group report doing exactly what you are suggesting, going out of state to a surgeon who does proper explant and does file through their insurance.

      1. Vannessa

        This is great info. Was not even considering my insurance covering procedure. Has anyone had any luck with BCBS HMO? Has anyone worked with an attorney from start to finish to process insurance acceptance? I live in Ca and not sure how to start the process.

        1. Trisha

          Hi Vanessa –
          Did you get any information on HMO I have Anthem Blue cross as well in So Cal.
          please let me know. My email is [email protected]

          Thanks much!

    2. Leeann

      I live in Michigan too, wondering where you looking at outside of Michigan

  26. Cheryl Duet

    I have both Medicare and a secondary insurance with BC/BS of louisiana does anyone know if they pay for explants and a full Capsulectomy

    1. Beth

      If you get an answer please let me know. I live in Louisiana as well and have the same insurance, Medicare and BCBS. I already found a doctor that accepts Medicare. This was about 5 or 6 years ago. I was ready to do it until I found out that neither insurance would cover reconstructive surgery.

    2. Kat

      Medicare does….but not for lift

      1. Donna Ziemer

        Hi Kat. How did you get Medicare to pay? I found the “Patient’s Request for Medical Payment”, form CMS-1490. Is that what you submitted? You can text me or call as well, 949-422-3789. THANK YOU!!!!!!!!!!!!!!!!!!

    3. Margie Holland

      In case you’re still interested I have same insurance as you. My entire procedure was completely covered by my insurance. Also, after recovering from explant in my routine mammogram some abnormal tissue in both breast was found. My dr had to do a surgical biopsy on both breast. He used same incisions from explant bc it could not be done with a needle. Insurance again paid in full. Thankfully, all test were benign.

  27. Kel

    Hi I’m wondering since Medicare cover explants, do HMOs like Kaiser cover it? Just wondering if anyone has any experience with Kaiser?

    1. Terri

      I agree that Medicare will cover, but the problem is both the surgeons and Medicare. The surgeons won’t accept what Medicare wants to pay, and also will not submit the paper work to you, so that you can submit to Medicare. I have a e-mail into Medicare today May 7 if and when I here back I will advise in a reply. When it come to Medicare and implants/explants Medicare is a real problem. If anyone can give any additional help it would appreciated!

      1. Donna

        Hi Terri. Any luck with Medicare? I explanted July 7 and am just beginning the process to see if I can get any reimbursement. Please let me know if you hear from them and I will do the same! Fingers crossed, prayers continuing!

      2. Deborah

        I am going to a consultation next week with a PS that Medicare gave me. This way I know for sure he takes Medicare. I looked him up and he’s rated highly.

    2. Jennifer Elliott

      Hi Kel!
      I have Kaiser HMO here in GA, and was very doubtful that Kaiser would cover explant, but I read a post about a month ago on the BII FB page where somebody had Kaiser in CA and she got hers totally covered! So there IS hope!

      1. Kat

        Former kaiser employee and yes, KP does cover explant but only that…….

        1. Celeste webb

          Hi Kay, I have my first appt tomorrow via video chat so you have anything I should say or not to get Kaiser approval. I’m so nervous and I need them to cover this.

  28. Sherri

    (BCBSIL PPO) With implant displacement, grade 4 capsule contractures, and suspicion of rupture of at least 1 implant, which CPT code should be used? Also, for the ICD10 codes, am I able to use more than one code? For example, would I be able to use these 3?
    T85.848A – Pain due to internal prosthetic devices, implants and grafts.
    T85.44XA – Contracture of Breast Prosthesis
    T85.43XA – Rupture of Breast Prosthesis

    1. Nicole

      Hi Sherri,
      I would use as many codes as applies.

    2. Michelle

      Did you have any luck Sherri? I have the same insurance so any information would be helpful. Thank you.

  29. Leslie

    Does anyone know if Tricare would cover any of the surgery? I’m just starting the research process. I will be contacting my insurance carrier to confirm. Any questions that I should ask or steer clear of?

    1. Susie

      I am with Tricare as well and trying to get this process started. Have you found anything out?

      1. Cyndi

        Has anyone found out if Tricare will cover the En Bloc?

        1. Samantha

          I am also with Tricare and would love an answer.

    2. Tracie

      Did you find out if Tricare will provide any coverage? I also have Tricare/Humana Military

    3. Saby

      By any chance did Tricare respond to you if they covered.. I am station in Kentucky and seeking information. Have not called tricare yet. I do see my primary doctor on the 29 of October. Want to know what would be the correct information.

    4. Lisa

      Hi Leslie….did you ever find out of Tricare covers any of the surgery? I am just starting my journey with them and could use any guidance if you had any luck. Thanks!

    5. Shana

      I have Tricare as well and would like to know what you found out.

    6. Dee

      Hi! Did you get any answers?

  30. Deborah Altmann

    I didn’t understand about the NPI number? Do I need to do that for myself?

    1. Micala

      The NPI (National Provider Identifier) Number is a 10-digit numerical identifier used to identify an individual provider or a health care entity. This can be found on google. For an example search Dr. Jane Smith NPI number. You can also go to NPIdb.org and search the doctors name.

    2. Kat

      Nope that is the providers NPI

  31. vanessa

    Hey whats the status? im going through the same thing

  32. Alicia Evolga

    Hi Nicole

    Would love your help/input! My insurance company (BCBS) decided to deny my claim for coverage despite me having a rupture, because the doctor (Dr Dev in Florida) was out of network. Not because the codes were incorrect or anything like that. I should technically have 70/30 benefits (30% my responsibility) with a $500 deductible if the doc is out of network as this procedure should be covered for me (up to $3000 max for out of network). However, they found a loophole saying that because Dr Dev and the office do not deal with insurance at all, they don’t have a contract/negotiated reimbursable rate in place with insurance, so in this instance they used “Medicare rates and/or what other in-network providers are currently accepting for this service”, which she said was $378!

    So I’d like to appeal their decision, which they said I need to state WHY I am appealing and what outcome I want. So I’d love help from
    on how I can “explain” WHY I am appealing aside from saying “this isn’t fair”, lol. Can you help me phrase somewhat sophistically that using a Medicare rate of $378 is egregious, especially as this surgery is not as commonly done for patients in that category (a guess on my part!), so how can they use that as a basis for what they will cover when a patient has out of network benefits? Would it help me to call a few other surgeons’ offices in my area and ask what they are reimbursed by BCBS for the surgery?? I have heard of successful appeals stories and would love to be one of them.

    Thank you in advance!! 💚🙏🏻

    1. Suhail

      Do you found any doctor in Florida the acceptance BCBS?

  33. Kim

    I need a doctor in PA or south NJ

    1. Tori

      Dr Buinewicz

  34. Diann Brown

    Hi Victoria ,
    I too am wondering if Medicare will cover en block and what is needed to get this done. If you were able to get any answers could you send me what you know. Thanks
    Diann

  35. Mary

    Thank you!

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