Explants May Be Covered by Insurance
Whether you are under a national, provincial or state health care plan or private insurance explants may be covered by insurance for what are deemed to be the accepted medical reasons to explant which generally are rupture, significant capsular contracture, pain or infection/tissue necrosis. In any event, get a full copy of your health insurance policy and read about their specific coverage for explantation of breast implants which is usually found on the EOC – Evidence of Coverage page(s) of the policy. Some policies will exclude covering explant for breast implants placed for cosmetic reasons and some may have inclusions for other reasons. Obviously reconstruction is not considered cosmetic and explanting reconstruction is usually covered by health insurance policies. Please note, health insurance policies do not cover for breast implant illness symptoms or autoimmune symptoms so avoid discussing these at medical appointments for obtaining insurance coverage as it may result in a denial.
Many ladies are denied in the initial application process but have success appealing so being persistent with insurance companies pays off. There are also law firms popping up to help ladies being denied explant coverage by insurers.
Here is a helpful link for navigating insurance coverage in the U.S: http://www.breastimplantinfo.org/insurance-coverage-for-breast-implant-removal/
Procedure and Diagostic Codes for Explant
in North America
Procedure and Diagostic Codes for Explant in North America
Insurance Procedure Codes CPT for Explanting Breast Implants:
19371 – 50 Periprosthetic capsulectomy breast, the 50 is the modifier for Bilateral
Insurance Diagnostic Codes ICD10 for Explanting Breast Implants:
T85.49XA – Mechanical complication of breast prosthesis and implant
T85.79XA – Infection and inflammatory reaction due to other internal prosthetic devices, implants, grafts.
T85.848A – Pain due to internal prosthetic devices, implants and grafts.
T85.44XA – Contracture of Breast Prosthesis
T85.43XA – Rupture of Breast Prosthesis
N64.81 – Breast Ptosis
N64.4 – Mastodynia
If Surgeons Refuse to Assist you With Coverage - Advice from Another Breastie
If Surgeons Refuse to Assist you With Coverage:
Advice from Another Breastie
I wanted to provide some info regarding insurance and some helpful tips that might lead in a direction of getting your upcoming surgeries partially covered, or for getting your already explant partially reimbursed. Please note I have Blue Cross/Blue Shield so I cant guarantee this info will work for all insurance providers. However, I come from a medical background as well as a medical filled family and we have gotten real good at dealing with insurances J also the key with insurance companies is: Keep on swimming. Meaning, don’t give up!
As we all know most of our Plastic Surgeons as well as Surgery Centers are not ‘in network’ providers… which is why we are paying out of pocket. Also they deem our explant as ‘elective or cosmetic’ so they don’t plan on covering us. So we must take matters into our own hands.
- You must get a good insurance agent on the phone! There are hundreds so if you aren’t getting anywhere with one; politely hang up, and call back! I promise you wont get the same agent. I speak English, so when I get someone from another country that I can’t understand well I ask to speak to an English-speaking agent in my zip code or city. This helps sooooo much! In my experience local agents are very kind, patent, and willing to take the time.
- Explain the situation of your health, and tell them you need an urgent surgery as you are in a lot of pain due to your implants. Let them know that there are a few specialist that do this surgery, and the ones in your area are either booked too far out or do not specialize in the removal of all that is necessary. From here they are going to ask a ton of questions about the doctor and surgery center. If you have this info then great!! If not tell them they can email you the form and you will send to the doctor’s office to fill out. If they fight you on this, ask for a supervisor. I had to speak with 3 agents before the 4th agent said, that’s no problem I’ll email you the form. P.s there were a few questions on this form and all can filled out by you, no need to send to PS.
- NPI number (this can be found on Google)
- Phone, fax, and Codes
- The form I received is called a “Medical Care Review” this is not a claim form. However if you have already explanted you will probably be receiving a claims form and adding all this info. You will also want to know the codes to use. (see codes attached) the first CPT code is for the explanation of explanting, the ICD-10 codes are to explain why. I used the 3rd ICD-10 code, as I know that pain rules over infection, or cosmetics, etc… (According to insurance rules, not my own opinion).
- I sent this form back to my agent (same agent the entire time, they will walk you through the whole process). Once this is all completed and sent back, you wait.
- I then received a form that was to be sent to my doctor again for extra needed clarification. It asked:
- What was reason for putting in implants? Cosmetic (For me)
- Type of implant being removed?
- Radiological reports (if applicable) I had none so wrote N/A
- Operative Reposts (if applicable) I had none so wrote N/A ** Ladies who have explanted this is good place to put your operative notes.
- Once you send this back to agent then you are done, and wait for your review of Approval/Allowance.
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