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 27 Comments

  1. Carol Winkler

    Thank you for this helpful information. The surgeon who removed my implants does not take insurance. Also, in the op report, he refused to acknowledge that my symptoms were caused by my implants. I went to him because he is experienced in doing and block surgeries. Do I have to include his Op report when filing my insurance claim? My functional medicine doctor believes in BII Recommended I get an Explant.

  2. Beth

    How long did it take to get the approval from insurance?

  3. Sasha

    What are the cpt codes please

  4. Coleen Gacesa

    Upmc insurance. Ruptured implant. Any surgeons in Pittsburgh area? Thank you.

    1. Patricia Jean

      Well that’s disappointing. Pittsburgh is a major medical center and UPMC is top notch. Yet not one Pittsburgh surgeon is on the list for Pennsylvania! How can that be? (I am in the same boat, thought with a more flexible insurance plan. UPMC would be my first choice, though. @Coleen Gacesa, Please let us know what you find out.)

    2. Jen

      Hi Colleen. I’m in Pgh too, have you received any recommendations on surgeons??

  5. Sylvia Miranda

    Hi Robin, I saw your message.. I have Kaiser in Southern California, I have BII and experiencing a lot of pain. I’ve been dealing with them for over a year. I have done appeals and Plastic Surgery keeps on denying me! I’m so frustrated and I’m in pain everyday ..had to go to emergency because I felt lot of pressure in my chest.. I have no problems with my heart so it’s obvious that my Implants are hurting my body.. I got them in 2007 so I had them for 16 years. Don’t know what to do… anyone can help ? Thank you

  6. Linda Arnheiter

    I am looking for BII surgeons in my area. Any good resources? thank you

  7. Juany Quinonez

    Hi my names is juany 43 years old, literaly my implant are killing. I talk to my insurance company i have BlueShield PPO and the only way they would pay is “medically Necessary” when I could different plastic surgeon from my network. the wont take the insurance un less cancer. the only thing they said was you pay to putted in, so you should pay for take them out. Can letter be from primary doctors or my specialist be sufficient. I ll have to submit a claim can s some one tell me what document ill be would i need? sorry my mind is running super slow

  8. Juany quinonez

    Hi, my name is Juany quinonez im 42 years old I had my first implant surgery 2010 and 2010 I decide to get new implants, but since the first implants I started getting symptoms from 2010 to 2019 I be been to the emergency room 35 times just in one hospital 10 time I was impatient and was there between 4-8 days and the other ones were went to ER help with terrible migraine I also have my doctors they have done multiple tests for the reason I’m getting sick and everything looks normal. I have Florida blue PPO I have called two doctors from in network and still are saying I have to pay. Since June I’ve been struggling with brain fog and seizures so far I had 5 all tests they did every kind of test possible and everything came and it was clear please help me

  9. Kristen Barone

    *put in cosmetically originally.

  10. Kristen Barone

    I have community Healthchoice silver marketplace insurance. They said most likely my ruptured implant and 4 doctors stating my medical issues and 3 doctors saying they need to come out due to medical issues and the fact that I have a cancer gene that makes me more likely to get cancers won’t be covered but I can try. Have you heard of any patients with marketplace insurance getting explants/lifts covered on marketplace hmo insurance if out in originally as cosmetic?

    1. Kelly Schemers

      Kristen, are you in AZ or IL by chance?

  11. Elizabeth (Lisa)Mauger

    I will be sending to Champva any luck with payment.

    1. Veronica

      I have Champ also, did you have any luck?

    2. Michelle Foley

      Hi, I have Medicare that will pay for my ruptured right implant but also I have Tricare for Life – is that that the same as Champ? I know Champus is military, they’ve been there for me in past ( unrelated) issues.

      1. Beth

        Another Breastie who gave the advice. Has there been any update from Blue Cross/Blue Shield about your surgery? Were you reimbursed?

  12. Robin Garrawsy

    Has anyone dealt with Kaiser Permanente in SoCal?
    I have Medicare Senior Advantage. I had reconstruction after double mastectomy.

  13. Susie Russell

    How do you contact Medicare I have secondary as well . My Dr doesn’t take insurance

    1. Patricia Jean

      I would like to know this too!

  14. Constance

    This was really great information to know. My plastic surgeon does not do insurance. So will I be able to send it to my Blue Cross Blue Shield anyways?

    1. Steph

      Wondering the same thing!

    2. Lindsey

      I was wondering this also. I also have blue sheild

  15. Deb

    Thanks so much. This is going to be helpful.

Leave a Reply