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, pain or infection/tissue necrosis.  Whatever your coverage, get a full copy of your health insurance policy and read why and how you may be covered for explantation 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.  Reconstruction is not considered cosmetic and explanting reconstruction is usually 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 denied in the initial application process but have success appealing so being persistent with insurance companies pays off.  There are also law firms popping up to help ladies being denied explant coverage by insurers. 

In the United States 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:

19330 – 50  Removal of mammary implant material, the 50 is the modifier for Bilateral
19371 – 50   Periprosthetic capsulectomy breast, the 50 is the modifier for Bilateral

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.

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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 31 Comments

  1. Natalia Ornelas

    Hello,

    I met with a surgeon not on this list but will do a capsulectomy and is trying to get approved by my insurance. I’m really nervous though since he’s not a micro surgeon. I have mentor textured silicone implants 400cc for 16yrs. He’s going to try and get me in before year end since I already met my deductible. I do have an appointment with Dr Parrett in December and really want to get it done with him but he likely won’t get me in until new year. What should I do??

    1. Nicole

      Hi Natalia,
      Microsurgery is not actually required during explant. The most important piece about explanting is that the surgeon removes all the capsule tissue so as long as he is dedicated to removing all capsule tissue, he should be a good choice.

  2. victoria l gillotti

    Can anyone tell me Medicare covers explantation/enbloc? Or Federal BC/BS? The both together????

    1. Cynthia Whiteman

      I’ve been researching about this and it seems like Medicare will reimburse a little, not sure about Federal BC/BS, which I also have (basic option). I explanted last week and was told both Allergan implants were ruptured, so the doctor’s office is preparing a warranty claim for me. I am in one of the class action lawsuits so I emailed the attorney’s office to ask if I should sign & submit the claim. I also downloaded the Medicare form (https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms1490s-english.pdf) and plan to take it to the doctor’s office when I return on Thursday to see what they say. They do not file for me. I am on FB if you want to message me & we can share info.

  3. Tambra L North

    Hello!! I am explanting with Dr. Chun this month and yes like many other women I have all the symptoms. I am suffering. My surgery is going to cost 17k…My ins will not cover it even though I am dealing with many issues. I do have a question about blood work and results and if anyone has had this happen….Total bilirubin levels and alkaline phosphate and being higher than they should be?.I was diagnosed with Gilbert’s syndrome because they could not find anything else…This goes hand and hand with the liver in any other case with these type of elevation. I am nervous about all this but am praying I get better.

  4. Cathy McKenzie

    I have been on state insurance in Indiana for over 12 years. My implants have been in for 21 years. My health is so bad that I cannot work. I can’t seem to find a surgeon who takes state insurance. Have you heard of any surgeons who will take state insurance?

  5. Felicia Arredondo

    Is there a good explant surgeon in so cal?

  6. Lori Soller

    My insurance will cover my explant surgery. I have silicone implants for 38 years and they have been ruptured for 25 years. The problem I can’t find a plastic surgeon who will do it with my insurance. Even the doctor that is on my insurance plan. What else can I do please?

  7. Angel

    Do you need a referral from your primary care doctor? I had all the tests done, my GP doctor couldn’t find what Was causing all the pain…almost a year later, I’m in terrible pain mostly on one side I saw that insurance may cover for this.

  8. Rebecca King

    Hi! Thank you for all the info here! I explanted in Jan 20’ my procedure was “ Approved” however my PS was out of network. I paid My PS in full and need to recoup this money. Because she was out of network I did not get reimbursed based on my deductibles not being met in Jan. I had a contracture grade 4. Significant Breast pain ect.. it was coded properly and approved but went in out of network not allowing any reimbursement. My surgery was 13,000$ I’m on disability from this to start so I’m in great need of recouping this cost. How would I go about appealing this ? Thanks so much!!

    1. Nicole

      Hi Rebecca,
      Not sure how you will appeal this but I would ask your insurance company how to appeal it. Read your insurance policy carefully too to see if it requires you to use a surgeon in the network and if it has a provision for if you could not go to or find a surgeon in your area that was in the network. I have seen other women post that they had to prove the surgeons in the network were not able to or willing to do their explants properly so they could use surgeons out of the network. Also see the resources on this page which may be useful to you: https://www.healingbreastimplantillness.com/insurance-explants/.

  9. Tatiana Sola

    Hi! I have implants since 2003 and six months later I had an infection I had to get my implants removed wait six more months then replace the implants then had to go back in and remove connective tissue found small tumors in both breasts had to get those removed they when to UC Davis to get biopsy which were benign, however, breast cancer does run in my family. I have had ongoing implants infections with ongoing antibiotics which i had to stop in 2010 when I got pregnant. Right implant broke in 2012 and a former doctor at SutterGould seen me and he said it was just cosmetic and we can redo your implants with silicone I’m over it I need help I want the implants out and my boobs fixed please help me. Or guide me to a plastic surgeon that is an expert in my situation I did file a claim with mentor as well.

  10. Katherine Batey

    My daughter just got denied by Kaiser-Permanente. She has had symptoms since October. She is now to the point of almost unable to walk, has lost body mass, on and on. Initially when symptoms started, she was tested for everything under the sun. She did not suspect her implants because they are “saline” and had no clue what breast implant illness was. She never mentioned her implants to the doctor. Finally after almost 6 months when she did mention it he immediately put in a request for removal and today it came back denied. I feel helpless and she is feeling her life is about over. I cannot even begin to tell you how much she has deteriorated in the past 6 months. We do not have the money to cover this. Does she just die at this point? Is this real life?

    1. Nicole

      Hi Katherine,
      I’m not sure where you are located, there are a couple surgeons on the list that do offer proper explant inexpensively. Please write me back and tell me where you are located.

      1. Limary Gonzalez Sanchez

        Hi Nicole I am new to all this information and I’m going tru the same situation, is it posible for you to provide me with such information as well, thank you 🙏

  11. Lara

    Hello! Thank you so much for the info!
    So, I understand. The second form “Has” to be completed by your doctor? Is a general practitioner or your surgeon?
    Thank you!! Thank you!!

    1. Nicole

      Hi Lara,
      For clarification check with your insurance which doctor has to fill out that form.

  12. AUSRA

    Hi
    Do it’s possible only with US insurance?bicos I am from England but wanted to do explanat surgeons enbloc in the US ?
    Please help me with that I have mentor 🙁

  13. Candy

    Hello, I have the teardrop textured implants, unfortunately I can’t confirm this do to I don’t have my serial numbers and I have been trying to get ahold of The manufacture companies my doctor everyone I talk to no luck on either there two old and records have been destroyed. Told me to have them taken out have a surgeon get a hold of them with the serial numbers.. I no there on the recall list and they need to come out asap… so should I tell my PCd I’m experiencing more than half of the Bll symptoms.
    I’m so depressed and frustrated at this point don’t no what to do..
    I’m sick of all the pain in my chest I can’t stand it anymore I just want them out ASAP. The explant surgeon said I needed a referral so I have a doc appointment on the 19th
    I have state insurance. But I’m willing to pay using my credit cards.
    I can go on!! I just need some guidance…

    1. Nicole

      Hi Candy,
      Stay calm, if you can get your explant covered by insurance, do so! You have time. Just ensure whoever explants you does a proper explant which means they remove all capsule tissue as well as your implants. Read our complete website so you have the knowledge you need to navigate explant and healing: https://healingbreastimplantillness.com/.

  14. Priscilla Freeman

    Hi. I am going to use Dr. Straka from Kingswood, Texas for my Explant but as I am pre-filling out forms at home for my consult next week I see there’s a clause that says they are not taking any new patients with insurance and all surgery costs must be paid for upfront. UGH! 😩😫 I have Christus Spohn Healthplan and I’ve called twice to ask if they cover and they’ve said yes but I’m afraid I’ll get it done then they won’t cover?!! Plus how do I do it myself if the doctors paperwork already said they won’t deal with any insurance? How can I get approved BEFORE my surgery? Someone please help. Thank you in advance
    [email protected]

  15. Brenda Hearst Huntley

    I need a list of surgeons who know what they are doing. My nipples are leaking blood and implants are so bad they are shifting and moving up my neck, etc.

  16. Amanda hackney

    You were able to get it covered for dx of pain without any diagnostic tests? I have Bcbs ppo too and. Wondering about my success in getting it covered. Did they still allow you to use the surgeon you wanted despite being out of network? I’m assuming you had to pay our out of network fees/deductibles

  17. Alice Smith

    Does anyone have the procedure codes for facility fee and anesthesia? Thank you.

    1. Megan Ossinger

      This is what I’m needing as well. I haven’t been able to find them anywhere.

  18. Carole Rader

    Keep me posted

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