Category Archives: Private Insurance

Private Insurance Help


Follow these steps to try to get insurance coverage for your breast implant removal:

1) Find Out Whether Your Insurance Company Considers Removal “Medically Necessary”

Insurance companies cover services that they determine to be “medically necessary” to treat a disease or illness. Although you or your doctor may believe a service is medically necessary, insurance companies don’t always agree.

Most insurance companies will not cover any cosmetic procedures and some will not cover complications from previous cosmetic procedures.  However, many companies consider removal of breast implants medically necessary for patients with any of these conditions:

Unfortunately, insurance companies usually won’t cover the cost of breast implant removal for autoimmune or connective tissue diseases or other systemic complications. If you have any of the conditions listed in the bullets above, you should focus on those in your insurance claim because insurance companies are more likely to cover these symptoms.

How do I know whether my insurance company will cover the cost of removal?

To find out if your insurance company is likely to cover removal, you will need to look at your specific policy language. You can usually find this language in a document called “Evidence of Coverage” (EOC), this is also sometimes called a “Benefits Booklet.” It is a document (typically about 100 pages) that describes in detail the healthcare benefits covered by your health plan, including procedures that your insurance company will and will not cover.

You can access an electronic copy of your EOC through your online account on your insurance company’s website. You can also call the member services number on the back of your insurance card and ask an insurance representative for a copy of this document.  

What Do I Look For?

Once you have your policy, look for language about breast implant removal.  If you don’t see any language about breast implant removal, search for language on complications from cosmetic surgery. If you cannot find any specific language about breast implant removal, you should also look to see what your insurance company’s definition of “medically necessary” is. It is also important to check whether your insurance plan requires pre-authorization for any surgeries.

If you’re using an electronic copy, you don’t need to read the entire document. You can easily find terms using the “Control+F” keys on your keyboard. That will provide a “search box” that will search for any words you enter. Just enter the word “breast” or “cosmetic” or “medically” in the search box. If you are unable to find what you need in the lengthy document, call your member services line and ask for assistance to locate the correct pages.

2) File for Pre-Authorization

Most insurance companies will require that you get pre-authorization (also called prior approval or pre-certification) before the surgery. This means your insurance company reviews your relevant information and determines whether surgery is medically necessary. Then, the insurance company will let you know if it is likely to cover your surgery. However, that pre-authorization isn’t a promise that your surgery will be covered.

The easiest way to get pre-authorization is to have your plastic surgeon sign and submit a letter that lists your symptoms and explains why removal is medically necessary based on your insurance policy language. (Usually one or more of health problems listed on the bullets earlier in this article). Your surgeon should also enclose any medical documentation that provides proof of your symptoms. 

It is best if your plastic surgeon signs this letter to send with your insurance claim. However, if your surgeon is unwilling to sign the letter, another doctor involved with your care, such as your primary care provider, can sign. You can find templates for these letters here. If your doctor agrees to sign the letter, but won’t submit it to your insurance company, you will need to submit the letter before your surgery to ensure you receive pre-authorization.

NOTE: If you don’t get pre-authorization when it was required, the insurance company isn’t required to cover the surgery, even if it considers the procedure to be medically necessary.

3) After Your Surgery: Filing a Claim

If your surgeon is in your insurance company network, he/she should file a claim on your behalf. If not, you will have to pay upfront for the surgery and file the reimbursement claim with your insurance company. Even if you see a surgeon who doesn’t take insurance, you should still file a pre-authorization claim with your insurance company. If you didn’t seek pre-authorization before your surgery, you can still file a reimbursement claim.

In your reimbursement claim, you will need to submit your pre- and post-operative reports, along with a letter from the surgeon stating that the procedure was medically necessary.  

All articles are reviewed and approved by Diana Zuckerman, PhD, and other senior staff.

Sample Letters of Medical Necessity for Insurance Coverage of Explantation

If you want to have your breast implants removed for medical reasons, and want your insurance company to pay for it, you will need a letter of medical necessity sent from your doctor to the insurance company.  Most plastic surgeons are not experienced at writing these letters, but we are!  Below are several sample letters of medical necessity describing different medical reasons for needing to have your breast implants removed.

For augmentation patients, most insurance companies will only cover the cost of breast implant removal for capsular contracture, chronic breast pain, or ruptured silicone gel implants. For that reason, our three sample letters focus on those issues. However, if you have other issues such as seromas or autoimmune disease symptoms, please reach out to us and we can help you find a compelling way to explain your symptoms to your insurance company. Unfortunately, we have found including breast implant illness or other autoimmune or connective tissue disease symptoms in your insurance claim makes it more likely that your claim will be denied.  However, we can work with you to maximize your chances of being covered.

If you are using these letters without our guidance, please be aware that these are broad examples that need to be tailored to your specific case. Please make sure to edit all the highlighted portions and to make sure that the letter accurately reflects your symptoms. We would be happy to assist you in strengthening your letter by personalizing it on your behalf.  If you would like our assistance, please take our short survey and we will email you soon! You can also reach us at info@breastimplantinfo.org.

Letter for Ruptured Silicone Gel Implants – Here is our sample letter of medical necessity written for a woman with at least one ruptured silicone gel breast implant. Click here to download this letter as a word document you can edit.

Letter for Capsular Contracture – Here is our sample letter of medical necessity written for a woman with hard or painful breasts caused by capsular contracture (classified as Baker III or IV). Click Here to download this letter as a word document you can edit.

Letter for Breast Pain – Here is our sample letter of medical necessity written for a woman who has chronic breast pain or back pain caused by the weight of her implants, but does not have capsular contracture (her breasts do not feel hard). Click Here to download this letter as a word document that you can edit.

How to Appeal a Denial


If you disagree with your health insurer’s decision to not cover a service, you have the right to appeal this decision. Many appeals are approved. Some appeals are handled by your healthcare provider, but you can also appeal a decision yourself.

Follow these steps to file an appeal:

1. Gather all relevant information

The first step to appealing your insurer’s decision is to find out why your claim was denied. Get a copy of your denial letter and any document(s) submitted to your insurance as a part of the initial claim. This might include documents such as MRI findings, lab test results, operative reports, notes from your physician(s), letters of medical necessity, or medical bills related to the claim.

You should check your denial letter to find out when the deadline to file the appeal is. Your denial letter should explain when and how to file the appeal.

You will also want to get a copy of your insurance’s Evidence of Coverage document (sometimes called the benefit policy document). From this document you can determine what procedures your plan covers.

It can also be helpful to call the insurance company’s member services phone number. You can ask them for a detailed explanation of why the procedure was denied. If you can’t get a clear explanation that makes sense to you, you can ask to speak to a supervisor. Always ask the name of the people you speak with on the phone, write it down with the date you talk to them, and ask them to “put it in the record” that you’re working on disputing the claim.

2. File an appeal form or write an appeal letter

It is likely that your insurance company will have a standardized appeal form for you to fill out. If so, filling out their form will make the process move as quickly as possible. This form usually asks for most of the information you would include in an appeal letter.

If your insurance company does not have a standardized appeal form, you need to write an appeal letter asking your insurance company to reconsider their decision.   Even if your insurance company has a standardized appeal form, an appeal letter can sometimes add more persuasive evidence.

This is known as an internal appeal. If the internal appeal is denied, you can appeal for a review by an independent third party. This is called an external appeal. The decision made by the external board is usually final and can’t be appealed.

The appeal letter should include the following:

  • Your identification: your name, claim number, policy number, member ID number and any other information that will help identify you.
  • Reason for denial: quote the exact reason for denial that they explained in the denial letter.
  • Reason why you disagree with the denial: explain why you think the procedure should be covered. To make your case stronger, you can insert relevant language from your insurance policy document that indicates the procedure should be covered. You can also get a letter from your doctor explaining why the procedure is medically necessary and include medical document(s) that prove medical necessity.
  • What you are requesting: Ask them to reconsider the denial and approve your claim based on the information you provided in the letter.

Click here for a sample appeal letter.

3. Contact your state’s Department of Insurance

If you need help filing an appeal, you can contact your state’s Department of Insurance for help. You can also contact them if you need to file a complaint against your insurance company. Click here to find your state’s Department of Insurance website.

Please contact the Breast Implant Information project for help filing an appeal at info@breastimplantinfo.org.

All articles are reviewed and approved by Diana Zuckerman, PhD, and other senior staff.

Sample Appeal Letter

Here is a sample appeal letter written for a woman with severe capsular contracture and a ruptured implant who was denied coverage for her breast implant removal surgery. For help writing your own appeal letter, contact us at info@breastimplantinfo.org. Click here to download.


Breast Implant Removal Office
555 Smiles Way
Healthytown, DC 55555

April 6, 2018

XYZ Claims Department
Attention: Appeals
167 Daisy Lane
Milwaukee, OK 12345

RE: Appeal for Denial of Claim Submitted by Jane Doe

Group/Policy number: 1425-2345-1234
Date(s) of service: February 31, 2018

Dear XYZ Claims Department:

I am writing on behalf of my patient, Jane Doe, to appeal XYZ’s decision to deny coverage for her breast implant removal surgery. I recommended the surgery because Ms. Doe has severe capsular contracture, which is causing her severe pain, restricting her movements, and interfering with mammography. In addition, her right implant is broken.

Your denial letter dated November 3, 2017, states that coverage for this procedure was denied because Ms. Doe’s “current condition does not meet the needed requirements and a bilateral breast revision is not medically necessary.” According to your letter, that determination was based on XYZ’s Coverage Criteria #567 and the details of her case. Your review concluded that because Ms. Doe has “not had breast cancer surgery or a breast injury,” you cannot approve the request for explant surgery.

We respectfully ask you to reconsider that decision. According to page 23 of my patient’s XYZ Medical Policy document (copy enclosed), Ms. Doe’s plan covers all “medically necessary” services that are not expressly excluded. Her plan does exclude cosmetic procedures; however, Ms. Doe’s implant removal is NOT a cosmetic procedure. Although Ms. Doe initially had the implants placed for cosmetic reasons, I recommended permanent removal solely to treat her present medical condition.

A review of XYZ’s Coverage Criteria #567 confirms my view that removal of her implants should be considered medically necessary. The guideline states:

Removal of breast implants for any of the following conditions may be medically necessary:
– Broken or failed implant;
– Infection;
– Implant extrusion;
– Siliconoma or granuloma;
– Interference with breast cancer;
– Breast pain; and
– Painful contraction”

Ms. Doe meets several of the above-stated criteria. I diagnosed her with Baker Grade IV capsular contracture (i.e. “painful contraction”) in her left breast, which is causing her chronic pain, restricting her movements, and interfering with mammography. Because of the pain, Ms. Doe regularly takes pain medication. Additionally, the MRI detected that Ms. Doe’s right silicone gel implant has broken (failed).

Consequently, based on the aforementioned language of the XYZ Medical Policy document and XYZ Coverage Criteria #567, XYZ should consider Ms. Doe’s implant removal a medically necessary procedure. Surgical removal of breast implants is the standard medical treatment for severe capsular contracture. The surgery is not intended to improve her appearance, rather it is intended to relieve her pain and restore her functioning. There is no other equally effective treatment available to Ms. Doe that is more conservative or less costly. Without removal, Ms. Doe will continue to experience severe pain and restricted movement, and her capsular contracture will make future screening mammograms difficult, if not impossible.

Based on this information, I request that you reconsider your denial and approve coverage for Jane Doe’s breast implant removal surgery. For your convenience, I have enclosed copies of all Ms. Doe’s relevant medical records. If you need additional information, please do not hesitate to contact me at (111) 111-1111 or doctor@iworkhere.org.

Thank you for your immediate attention to this matter.

Sincerely,

Dr. David Healthcare, Chief of Breast Implant Removal Operations
NPI# 1234567890

Enclosures:
Ms. Doe’s XYZ Medical Policy
Ms. Doe’s Office Visit Notes from 11/21/2017
MRI Report from 12/10/2017
Ms. Doe’s post-operative report from 2/31/2018


	

Breast Implant Problems? Obamacare Can Help!


If you’re having problems with your breast implants, there’s a chance you could benefit from the Affordable Care Act (ACA, or “Obamacare”).

An important change was made when the Affordable Care Act was passed: health insurance companies could no longer refuse to pay for health care arising from a pre-existing condition. Pre-existing conditions are health problems you had before joining an insurance plan. For example, your health insurance company can’t refuse to cover your insulin medication if you were diagnosed with diabetes before buying their plan. This is important because before the Affordable Care Act, insurance companies considered breast implants a pre-existing condition. They refused to cover any breast implant problems and sometimes even problems that occurred in the breast tissue.

Now insurance companies are usually required to pay for “medically necessary” services. Most insurance companies define “medically necessary” as a service that is required to improve your health or keep you healthy. Although some insurance companies say they do not cover services related to cosmetic surgery, many have exceptions when those services are deemed medically necessary. It is important that you read the policies carefully before you choose!

Based on our experiences working with women having problems with their breast implants, we have found that many companies consider removal of breast implants to be medically necessary for these conditions:

  • Ruptured silicone gel breast implants
  • Severe capsular contracture
  • Infections that don’t go away
  • Chronic breast pain
  • ALCL (a rare cancer of the immune system)

Additionally, insurance companies such as Aetna, UnitedHealthcare, and Cigna tend to have good coverage for medically necessary breast implant removal if you meet their criteria that include the conditions listed above. The language that each policy uses can vary by state and plan type, so be sure to look for the language regarding breast implants in the specific plan you are considering.

There is a window of time called “Open Enrollment” each year when you are able to sign up for a plan through the health insurance marketplace. If the Open Enrollment period has ended, please email us at info@center4research.org and we can help you look into other options. Otherwise, read below to see how to sign up for health insurance through the Affordable Care Act or Medicaid.

How Do I Sign Up During Open Enrollment?

Starting in early November, you will have the opportunity to choose an affordable health insurance policy through the government’s Health Insurance Marketplace. This Marketplace helps you to shop for insurance plans that everyone can afford.  The time to sign up is called the Open Enrollment period, and it only lasts from early November to mid-December for coverage in the following year.  If you want health insurance so that you can get your implants removed or any other medical coverage at any point in 2020, it is important to start thinking about it so you are prepared when the Marketplace opens.

The open enrollment period for coverage in 2019 through the Health Insurance Marketplace has already ended,  but if you’ve recently lost your health insurance coverage, or have had a major life event, like getting married or having a baby,  you may be eligible to sign up for health insurance outside of the Open Enrollment period. If you follow this link: https://www.healthcare.gov/screener/ you can check whether you might be eligible for coverage in 2019 outside of the enrollment period.

This Marketplace allows you to shop for insurance plans and apply savings based on your household income. The lower your income, the less you’ll have to pay. Want to know how much your health insurance plan will cost through the Affordable Care Act? Use this calculator to find out.

Is Medicaid an Option?

In many states, Medicaid is available for free to any individual or family under 133% of the poverty line (about $30,000/year for a family of 4). Medicaid provides coverage for surgery or services that a doctor determines are medically necessary. You can find out if you are eligible for Medicaid at www.healthcare.gov.

Read here for more information on getting Medicaid coverage for your breast implant removal surgery.

Unfortunately, fewer people are eligible for Medicaid in states that did not adopt the Medicaid expansion provided by Obamacare.

 

All articles are reviewed and approved by Diana Zuckerman, PhD, and other senior staff.