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.
- 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.
- 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.
- Address
- NPI number (this can be found on Google)
- Phone, fax, and Codes
- 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).
- 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.
- I then received a form that was to be sent to my doctor again for extra needed clarification. It asked:
- What was reason for putting in implants? Cosmetic (For me)
- Type of implant being removed?
- Radiological reports (if applicable) I had none so wrote N/A
- Operative Reposts (if applicable) I had none so wrote N/A ** Ladies who have explanted this is good place to put your operative notes.
- Once you send this back to agent then you are done, and wait for your review of Approval/Allowance.
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Any luck with insurance coverage if implants are recalled
Hi Tiffany I have a bump on my collarbone too I’ve had X-rays ct scans blood work all seemed ok !! Was sent to rheumatoid specialist not that either – I believe mine is related to implants and sounds like what you’re experiencing !! I’m working on getting mine out have a consult in August .. worse decision I ever made was implants haven’t been healthy since 🙁
They should I had bilateral mastectomy due to CA 2009 but I have Medicare they are covering mine
I live in Georgia,
I’m a healthy 48-year-old female, who loves to run and loves the gym. I have 6 children and five grandchildren.
1 February 2025 I noticed a bump on my collarbone. It was very sore so I went to the urgent care. Urgent care did an x-ray. And ordered a CT scan of the chest. Both test came back negative. The nurse practitioner at the urgent care was so helpful… she wouldn’t give up, she knew she could see a bump and knew there had to be something there. I went to my primary care doctor to show him. He referred me to an orthopedic doctor. Orthopedic doctor put me on an anabiotic, also tried a steroid. Ordered an MRI of the collarbone. It showed an abscessed on my collarbone. They ordered a They ordered an aspiration test on this spot, when they tried to get fluid from the spot on my collarbone. It was almost impossible. They had to add saline just to get something out of the spot . One week later it tested positive for Cutibacterium Ances, they called it a false positive result .. One month after the 1MRI they ordered another MRI of my collarbone and the spot was bigger. During this time I was in chronic pain. The orthopedic doctor decided the spot needed to be removed. (All this time I had been reading about the Cutibacterium Ances caused by implants) the orthopedic doctor did surgery. Remove the spot and scrape down some of the bone on my collarbone. They did test on the bone and the spot they removed. The spot was a solid object with no liquid inside… only tested positive for Cutibacterium Ances. The orthopedic doctor referred me to the infectious disease, doctor. They put a port in me, and I’m receiving antibiotics every day for 12 days. I’m on day 5 and I’m in the worst pain, my entire chest, back, neck, and shoulder is in so much pain. When I asked the infectious disease doctor where I could’ve tested positive for this… he said it’s usually caused from surgery. The only surgery I’ve had is my breast implants. He doesn’t believe it was from my breast implants because they were done three years ago. I’m going to the plastic surgeon tomorrow that put them in. I’m hoping they will help me.. I need a doctor to say that my breast implants are the reason why.. so I can claim it on my insurance and my short-term disability. Has anybody had any symptoms of this?
Hi Tiffany, I’m glad to see you joined our facebook group and I hope you post about this in the group too. Many women have found Cutibacterium Acnes in capsules of their breast implants when pathology swabs were done.
I don’t know if this helps but I did read one of the girls say that an abscess was a symptom. One or two years after my implants, I woke up and my neck and head was completely turned to one side and wouldn’t move. I thought I slept wrong until I noticed it wouldn’t budge at all. I couldn’t even drive because I wouldn’t be able to check my rear view, side mirrors, blind spot. Ended up finding out it was due to an esophageal abscess. They said they would try antibiotics and steroids, if not I would have to get it drained. Thankfully, the combo worked but I did not know it was probably a symptom of BII until I read someones post this month! They had asked me if I had been very sick recently before that and I hadn’t!!
I haven’t located a recommended surgeon in Utah who accepts Medicare…
Hey did you have any luck with this? I have brca1 too and hoping to get some sort of coverage!