Does Medicare Cover Breast Implant Removal?

Health Compare
Dec 13, 2021

If you are a Medicare recipient and have received breast implants with a breast reconstruction procedure after a lumpectomy or mastectomy, you aren’t alone. In the United States, more than 50 percent of breast cancer care is done for women who are older than 65, and a large percentage of them choose to get breast implants.

There are two basic types of breast implants – silicone gel and saline. Both types last for an average of 10 to 20 years, but many physicians recommend their removal or replacement every 10 to 15 years even if there are no problems. And some women have theirs removed sooner because of complications or for cosmetic reasons. 

Today, one of the most common reasons for removing breast implants is that scar tissue hardens around the implants and causes discomfort or pain. This condition is known as capsular contracture. 

Some other common reasons for implant removal are: 

• The implant is leaking.
• There are calcium deposits building up around the implant.
• The patient has an autoimmune response or rejection of the implant.
• Tissue around the implant dies (tissue necrosis).
• The implant is causing pain.
• The implant is shifting or moving out of place.

While most people have their implants removed due to health complications, many do so for cosmetic reasons. 

If you have decided to have your breast implants removed due to a health issue, your Medicare benefits may cover a portion of the expense. The information in this article shows you how Medicare can help with this procedure.

How does Medicare insurance cover breast implant removal?

Your Medicare benefits cover your breast implant removal surgery if you meet the following qualification requirements:

1. Your health care provider, who accepts Medicare assignment certifies that the procedure is medically necessary for any of the following complications:

• The breast implant has a mechanical complication such as a rupture, leaking, failure of the implant, or implant extrusion. 
• You have an infection or an inflammatory reaction caused by the implant. This can include infection or rejection.
• There are other complications with the breast implant that can include siliconoma, granuloma, and/or capsular contracture that causes pain or disfigurement.
• The breast implant interferes with the diagnosis of breast cancer.

2. If you had breast implants inserted for a cosmetic reason and the procedure wasn’t covered by Medicare insurance, you may still qualify for implant removal surgery with Medicare coverage if you need implant removal because of any of the complications mentioned above.3. If you have breast reconstruction after a mastectomy, your Medicare insurance plan covers all stages of your reconstruction. This includes procedures necessary to create a symmetrical appearance even for an unaffected breast.

Medicare Coverage

Most breast implants are removed by a surgical procedure that requires general anesthesia. If your physician certifies that you must be admitted as an inpatient for the procedure, your Medicare Part A (hospital insurance) benefits cover this procedure. 

The physician ordering your hospitalization and the hospital must both accept Medicare assignment. Original Medicare Part A pays for your inpatient care and the surgical procedure as an inpatient. You are responsible for the Part A deductible for the current benefit period.  

If your procedure is done on an outpatient basis, your Medicare Part B (medical insurance) benefits cover a portion of the cost. You must have the procedure done by a physician that accepts Medicare, and in a medical facility that also accepts Medicare assignment. Original Medicare Part B pays for 80 percent of the final approved cost. You are responsible for the remaining 20 percent as well as your Part B annual deductible. 

If you have a Medicare Advantage (Part C) plan, you have the same benefits as you would under Original Medicare Parts A and B. However, your private insurance plan provider may require that you use health care providers, medical facilities, and medical suppliers that are in the plan’s set provider network. You may not have coverage if you go outside the network. You may also be required to get a referral from your primary care provider first before seeing a specialist or surgeon.