Breast augmentation is considered cosmetic and therefore not covered by health insurance companies. The health effects of most complications associated with breast implants is covered by insurance companies. The process begins by consulting with a plastic and 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 important to document all associated problems and symptoms. Complications such as rupture, implant capsular contractor, and implant infection will all have health implications if not treated.
Other complications including rippling, asymmetry or uneven breasts, and dissatisfaction with implant size do not pose any health hazards and are therefore not covered by health insurance plans. Documentation of implant capsular contracture must include the degree of implant hardening. Grade I or sometimes even Grade II breast implant capsular contracture are not covered by insurance policies.
Health insurance policies
In Grade 1 capsular contracture, the implant is normal and not firm. In Grade II breast implant capsular contracture, the implant is harder to touch, but visibly normal. Grade III describes a breast implant which is visibly deformed and hard to touch.
This grade, along with Grade IV which is associated with breast pain and tenderness to touch, are covered by insurance plans. Health insurance policies may pay for the capsulectomy (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. Most plastic and reconstructive surgeons are not providers for insurance plans. Preauthorization is therefore not essential prior to surgery.
To potentially improve reimbursements, some surgeons do submit preauthorization 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. Realize that insurance companies make profits by denying coverage for treatments and not by paying for every treatment deemed necessary.
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.