We have seen many reports of surgeons telling patients that explanation surgery is not covered by insurance and therefore are raising their cosmetic fees to capitalize on this growing population of patients.
Explant Surgery May Be Covered
According to the BCBS of TN medical policy, “removal of silicone gel breast implants for documented leakage and/or rupture is considered medically necessary.” In order to document the rupture or leakage, you must have diagnostic testing performed. This can be done in one of three ways:
We can tell you that in many cases, even with an ultrasound the insurance company’s Medical Director will request to see an MRI, so you may want to prepare for needing an MRI to get your surgery covered.
If your implants were placed for Reconstructive Reasons such as Mastectomy, the removal should be covered regardless of implant type. If your implants were placed for cosmetic reasons, the coverage process is more strict, but it is possible to have it covered. Insurance typically does not pay for intact implant removal- meaning you will need to prove with the above-mentioned diagnostic testing that you have a leak or rupture. Once you’ve done your diagnostic testing, you can send those results to your surgeon who will facilitate the insurance coverage process for you.
Your Insurance Needs to Approve the Surgery Before It’s Completed
This process is called Prior Authorization. During this process, the insurance company reviews your medical records and determines whether your surgery meets their coverage criteria, therefore deeming it medically necessary. Your surgeon will determine the procedure codes needed for your surgery in particular. However, if you want to verify whether implant removal is covered under your plan, you can use the code: 19330. This is removal of mammary implant material- meaning the implant is no longer intact. Will Insurance Cover Explant if my Implants Aren’t Ruptured? According to Aetna’s policy, it is possible to have an intact implant removed for “Members who exhibit cutaneous hypersensitivity-like reactions associated with breast implants and who have failed conventional treatments (e.g., antibiotics, oral corticosteroids, and topical corticosteroids).” Again, you would need to call your insurance company to verify your specific plan’s coverage criteria. To remove an implant that has not been ruptured or leaking, ask for coverage guidelines for procedure code 19328. For any procedure, also ask the representative for any documentation needed for prior authorization of your procedure. We also recommend you ask about codes 19370 and 19371 which refer to the removal of the capsule. Again, your surgeon may need to perform additional codes depending on your specific situation so before surgery you should get the full list of codes from your surgeon and ask your insurance company what your estimated out of pocket expenses may be for surgery.