Surgical tools on a green surgical sheet, representing breast explant surgery.

Tips for Getting Your Insurance Company to Cover Breast Explant Surgery

Getting breast implants can change a person’s life for the better. According to the American Society of Plastic Surgeons and the Plastic Surgeon Foundation, approximately 10 million to 11 million women in the world have breast implants. The American Society of Plastic Surgeons estimates that more than 400,000 women and teenagers undergo breast implant augmentation surgeries every year, with 75% for augmentation of healthy breasts and 25% for reconstruction after mastectomy.

In recent years, women have suspected that their breast implants have made them very ill. Breast implant recipients continue to report symptoms similar to those of autoimmune disorders including fatigue, muscle and joint aches, fevers, dry eyes and mouth, and occasionally poor memory or concentration.

Unfortunately, most women who want their breast implants removed for medical reasons and want their health insurance to cover it, will be denied coverage. Health plans refuse to pay for breast “explant” surgery on the grounds that such treatment is “not medically necessary,” or is limited by plan terms. Dealing with your insurance company to get the treatment covered can be confusing and complicated. Knowledge is power in dealing with insurance companies. Below are some tips to help you maximize coverage for breast explant surgery.

Know Your Coverage

It is important that you are familiar with your insurance policy. If you get health insurance through your employer (even if you pay some of the premium), you should request a copy of your insurance policy from your employers’ human resources department.

If you have an individual insurance policy, you can request a copy of your policy from your insurance company.

Pay Attention to Important Plan Terms

Below are some important plan terms that you will likely see in your policy. Make sure you understand these terms and how they apply to your situation:

  • Precertification or pre-authorization – most insurance companies require pre-authorization (also called prior approval or pre-certification) before surgery. See below for a more detailed explanation.
  • Proof of loss – you have an obligation to submit claims to the insurance company in a timely manner. Make sure you know how much time you have to submit your claims (e.g., 90 days).
  • Number of appeals and deadlines for submission – make sure you know how many appeals are allowed under your plan and what the deadline is to submit them.
  • Statute of limitations – some plans include a statute of limitations, which is the deadline or time limit you must file a lawsuit. If the plan does not specifically include a statute of limitations, then state laws will apply.
  • Binding arbitration – some plans may have a provision for binding arbitration, which means that you cannot file a lawsuit against the plan.

What is Medical Necessity?

Health benefits are only provided for services that are “medically necessary.” Insurance companies have policies or guidelines that decide if they will cover breast implant removal procedures. Most insurance companies will not cover any cosmetic procedures, and some will not cover complications from previous cosmetic procedures.

Some guidelines are available on insurance company websites, but in some cases, you may need to ask for them. Familiarize yourself with the medical necessity guidelines that are being used by your plan. Discuss the guideline with your surgeon to see how it applies to your treatment. Is the treatment medically necessary based on the guidelines? If you are submitting an appeal, then explain this answer in your appeal.

How to Request Pre-Authorization?

To get pre-authorization you will need to submit an insurance claim form and any supporting documentation from your plastic surgeon or doctors. Your health care team may help with this process. The insurance company will review your request and determine whether the surgery is “medically necessary.” If you don’t get pre-authorization when it is required, the insurance company isn’t required to cover the surgery, even if it considers the procedure to be medically necessary. However, pre-authorization isn’t a promise that your surgery will be covered.

Reimbursement Claims & Post-Service Claims

If your request for pre-authorization was denied and your surgeon is an in-network provider, the provider should file a post-service claim on your behalf after the surgery is performed. If, on the other hand, your surgeon is an out-of-network provider or does not accept insurance, you should file a post-service claim or reimbursement claim on your own. Check your plan to find out where to send the claim. In addition to the claim, you or your surgeon should also submit pre- and post-operative reports, bills or invoices, and a letter from the surgeon explaining why the procedure was medically necessary.

Appeals and Denials

If your plan denies coverage or a pre-authorization, it is important to understand your appeal rights and deadlines. These are in your policy and in denial letters. If your claim is denied, put your appeal in writing and submit it on time with a method of delivery confirmation. Submit treatment records with your appeal. Even better, submit a letter from your treating doctor explaining why your treatment is medically necessary based on the insurance company’s guidelines. Keep a copy of the appeal you submitted to the insurance company for your records.

Despite your best efforts, the appeal may be denied. It happens. It is frustrating. Do not lose hope. Appeal again. Usually, policies provide for two levels of appeal (know your policy).

Know when the second-level appeal is due. It could be as soon as 60 days, or as long as 180 days. As another alternative, your plan may offer an External Review. For more information about the appeals process, see our Health Insurance Appeals Module on CancerFinances.org.

Don’t Give Up

If you have exhausted your plan’s appeals process and your claim has still been denied, then litigation may be an option. It might be time to contact a lawyer.

Navigating insurance denials for breast explant surgery can be confusing and feel overwhelming. Don’t feel embarrassed to ask for help if needed.

Cari Schwartz is a senior associate with Kantor & Kantor, LLP. Kantor & Kantor is a contingency law firm that works with individuals and their families to ensure health benefits get paid. Cari represents clients seeking health benefits pursuant to individual policies and is proud to serve on Triage Cancer’s Legal Advisory Council.

About Triage Cancer

Triage Cancer is a national, nonprofit providing free education to people diagnosed with cancer, advocates, caregivers, and health care professionals on cancer-related legal and practical issues. Through eventsmaterials, and resources, Triage Cancer is dedicated to helping people move beyond diagnosis. For more information about health insurance and appeals, see our Health Insurance Resources.

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