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:
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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This Post Has 27 Comments

  1. 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.

  2. 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/.

  3. 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.

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