Medicare usually covers breast implant (saline or silicone) removal for any of these conditions:
- Painful capsular contracture with disfigurement
- Implant rupture
- Infection
- Implant extrusion (coming through the skin)
- Interference with the diagnosis of breast cancer
- Siliconoma or granuloma (silicone-filled lumps under the skin)
Medicare coverage can differ depending on the state where you live. You can check the specific Medicare policies on breast implants removal in your state here.
Whether or not Medicare will pay for your breast implant removal depends on many factors. Below are some questions that will help you figure this out.
Original Medicare Plan
Original Medicare means you’re enrolled in Medicare Parts A & B and don’t have a Medicare Advantage plan.
1) Is your surgeon a Medicare Participating Provider “who takes assignment?” If you aren’t sure, ask the surgeon’s office whether they “take assignment.”
- A surgeon who “takes assignment” has agreed to accept the Medicare fee as full payment for the surgery. The surgeon must submit the claim for your surgery directly to Medicare. Your surgeon CANNOT charge you, except for the deductible and/or copay amounts that Medicare doesn’t cover. Your surgeon should call the Medicare provider line to see if your surgery will be covered.
- Even if your surgeon doesn’t think Medicare will cover the surgery, you still should ask the surgeon’s office to call the Medicare provider line to check. Many surgeons don’t know that Medicare will cover breast implant removal, so it’s important to have them check.
- A Medicare Participating Provider who takes assignment IS REQUIRED to submit your Medicare claim within a year of your surgery. If they don’t, Medicare won’t pay and the doctor might try to get the patient to pay. That isn’t fair, so don’t let that happen to you.
- You can check for Medicare participating providers here.
2) Is the surgeon you are thinking of using a Medicare non-Participating Provider “who does NOT take assignment?”
- A surgeon who “doesn’t take assignment” can charge you up to 115% of the Medicare-approved fee. You might be asked for full payment upfront (at the time the surgery is done).
- A surgeon who does not usually “take assignment,” can do so on a case-by-case basis, so you should check to see if the surgeon is willing to “take assignment” from Medicare in your case.
- A surgeon who doesn’t take assignment may not be able to submit your claim to Medicare. You should ask the surgeon’s office who will be responsible for filing your claim. If the surgeon agrees to file, you should check to make sure it is filed soon. IMPORTANT: If it is not filed within one year of your surgery, Medicare will NOT pay the claim and you may be liable for the entire amount.
- If your surgeon won’t submit your claim to Medicare, you can fill out this form for reimbursement with Medicare.
3) Has the surgeon you plan to use “Opted Out” of Medicare?
- Surgeons who have “opted out” of Medicare don’t take assignment, submit Medicare claims, or limit fees to the Medicare-approved fee amounts.
- Surgeons who have “opted out” of Medicare are REQUIRED to notify the patient with a written contract. This contract confirms that a patient understands she is directly responsible for paying the surgeon whatever he or she charges and that she CANNOT seek reimbursement from Medicare.
4) Do you have a supplemental insurance plan in addition to your Medicare coverage?
- A supplemental plan might cover the deductible and/or copay amounts.
- Medicare is your primary insurance and will reimburse the surgeon. You will need to get approval from Medicare BEFORE going to your supplemental plan.
Medicare Advantage Plan
1) Are you enrolled in a Medicare Part C Advantage Plan?
2) Is your surgeon part of your Plan network? If you are unsure, ask your Plan.
Because Medicare Part C Advantage Plans deal with Medicare directly, you won’t have to submit a claim to Medicare.
If your surgeon is NOT in your Plan network of providers, you may have to submit a claim directly to your Plan, Your Plan may limit what they will pay for your surgery. IMPORTANT: To avoid unplanned expenses, check with your Plan BEFORE you schedule surgery with a surgeon who is outside your Plan network.
3) Does your Plan require that you get pre-approval for your surgery and, if so, have you received pre-approval?
Most plans require that you get permission from your Plan before the surgery. If you don’t get pre-approval, the Plan might not cover your surgery.
Are you on Medicare and Medicaid?
People who are enrolled in both Medicare and Medicaid are called “Dual Eligible Beneficiaries.” They are enrolled in Medicare Part A and/or Part B and receive full Medicaid benefits and assistance with Medicare premiums.
If you’re dual eligible, your medical services generally are usually paid at the Medicare-approved amount. Because it depends on your unique situation, you should speak to your primary care doctor about the specifics.
All articles are reviewed and approved by Diana Zuckerman, PhD, and other senior staff.