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Insurance Coverage on Breast Surgery Complications

Know if Your Insurance will Pay for Your Beverly Hills Breast Surgery

Breast augmentation is considered a cosmetic procedure; therefore, health insurance companies do not cover this procedure. However, insurance companies cover the health effects of most complications associated with breast implants. At Simply Breasts, we are prepared to coordinate with your health insurance company to get all the information and requirements you may need in processing your breast surgery procedure.

How to Approach Your Health Insurance Company

Once you notice a complication in your breast implants, you should consult with our Beverly Hills breast reconstructive surgeon as soon as possible. Documenting the nature of the problem in severity, character, and length of time it has been ongoing, are all important to obtain insurance coverage. It is also helpful to document all associated problems and symptoms.

Complications, such as rupture or implant capsular contracture and implant infection will all have health implications if not treated. Other complications do not pose any health hazards and are therefore not covered by health insurance plans.

  • These complications include:
  • Rippling
  • Asymmetry
  • Uneven breasts
  • Dissatisfaction with implant size

Documentation of implant capsular contracture must include the degree of implant hardening. Grade one or sometimes, even grade two breast implant capsular contracture is not covered by insurance policies.

  • Below are the characteristics of each capsular contracture grading:
  • Grade one capsular contracture is when the implant is normal and not firm
  • Grade two breast implant capsular contracture is when the implant is harder to touch but visibly normal.
  • Grade three describes a breast implant that is visibly deformed and hard to touch
  • Grade four is associated with breast pain and tenderness to touch

Only grades three and four are covered by your insurance plans. Health insurance policies may pay for the capsulectomy or the removal of tight scar tissue around the implant and the implant removal, but they do not pay to have the breast implant replaced. Implant replacement in face of capsular contracture is considered elective. Patients, therefore, have to either pay out of pocket for implant replacement or for a breast lift if one should be necessary.

What to Do if Your Insurance Denies Coverage

Most plastic and reconstructive surgeons are not providers for insurance plans. Pre-authorization is therefore not essential prior to surgery. To potentially improve reimbursements, some surgeons do submit pre-authorization requests to insurance companies prior to undertaking a procedure for implant complications. Even with pre-authorizations, insurance companies have denied payment for breast implant surgeries.

You must realize that insurance companies make profits by denying coverage for treatments and not by paying for every treatment deemed necessary. We can help you as much as we can, but patients should act on their own behalf and contact their insurance carrier to request coverage. If coverage is denied for the particular surgery for implant complications, appeals can be made and have been known to be occasionally successful.

For more information on insurance coverage, please do not hesitate to call us at (310) 278-0000

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If you need assistance and don't see the resources you need on our site, please do not hesitate to call us at (310) 278-0000.

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