Breast Implant Revision Surgery – does Medicare or my health insurance cover Breast implant replacement?
August 31, 2020
December 7, 2021
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By Dr. Andrew Campbell-Lloyd

Breast Implant Revision Surgery – does Medicare or my health insurance cover Breast implant replacement?

We see a lot of patients for “second opinions”, and one of the most common reasons is to discuss breast implant revision procedures. One thing that is interesting about that, is the fact that patients can then compare the quotes they receive from us (check the price list on our website if you are interested) and those from the other surgeons they have seen.

What we have learned is that many ladies are being terribly misinformed about the cost of their surgery. Why do I say that? Because it is abundantly clear that patients are being told time and time again that an item number will apply when they are having breast implant revision surgery with replacement of their implants. Which fascinates me, given that there is obviously no insurance coverage for having a cosmetic breast augmentation procedure in the first place.

“…the costs associated with replacing cosmetic breast implants rest with you and you alone…”

Let’s just make it clear at the outset…despite what you may have been told, item numbers 45553 and 45554 are not in any way intended to be used for patients with cosmetic breast implants, even if you have a painful capsular contracture, or a rupture or any other complication. This is important to understand. If the original intention of those implants was cosmetic, then the costs associated with complications of that cosmetic surgery rest with you and you alone (or at least, that is what Medicare and your private insurance intend).

Having said that, Medicare and your private insurer WILL cover the costs of implant removal in the context of implant rupture or capsular contracture. Item number 45551 does apply to any patient having explant surgery, as long as a breast implant is not being put back in. However, we can perform procedures to reshape and lift the breasts (a breast lift is also referred to as a mastopexy) at the time of removal to create a more aesthetically pleasing breast, without altering the applicability of that item number.

Ok, so here is the thing…up until November 2018, there was an item number that could be applied to almost any case where an implant was removed and REPLACED regardless of the reason that the implant was put in originally. For ladies who had previously had cosmetic breast augmentation with implants, whenever they had breast implant revision surgery, for almost any reason, they were using their insurance to cover the costs of the hospital and implants (and that represents a big saving to the patient, and a big cost to Medicare and the insurer).

After November 2018, the rules changed. For a good reason.

Basically, Medicare decided that they shouldn’t be responsible for cosmetic implants (and come on, we know they’re right). These are things that were put into people with no medical reason. They were a choice. And as such, Medicare made it clear that they wouldn’t continue to accept that revision surgery for cosmetic implants was a medical necessity. If you decided to cosmetically enhance your breasts, then the responsibility for any breast implant revision surgery rests entirely with you, and not with Medicare (ie. taxpayers) or the private health insurance system (which of course, is underwritten to a large degree by taxpayers). What Medicare really wanted to avoid was a legacy of ongoing financial obligations to a patient who had a cosmetic breast augmentation, given that those implants were never intended to last a lifetime. It seems hard to justify the taxpayer covering in any fashion the likely 3-4 revision procedures a patient may require over their lifetime after cosmetic breast surgery.

Ok then, what about item numbers. What is the deal? Well, currently we have a few item numbers that function for the purposes of revising breast implants. The key is in the detail and descriptors for these item numbers. What it comes down to is this: if the implants were placed in the context of cancer reconstruction, correction of a congenital breast difference (like tuberous or constricted breats or significant asymmetry) or surgery in the context of other breast disease or trauma, then Medicare and the private health system will cover the cost of revision surgery for the lifetime of that patient.

But the simple fact is that small breasts are not a recognised medical problem (yes, I know there can be psychological issues for some ladies associated with their small breasts, but at the end of the day, we could make the same argument for cosmetic rhinoplasty, cosmetic tummy-tucks and a bunch of other procedures and Medicare won’t cover those either).

Understanding this issue requires that you read carefully the descriptor for items numbers 45553 and 45554. It states that an item number for implant replacement will apply only if “it is demonstrated by intra-operative photographs post-removal that removal alone would cause unacceptable deformity”.

The problem obviously is that this is rather ambiguous. What is an unacceptable deformity? That is a subjective assessment. And Medicare is assuming that your surgeon, who knows only too well that an item number should not be used and who has a sound sense of personal ethics, won’t try to.

What Medicare has intended with that wording, and this has been reinforced by the Australian Society of Plastic Surgeons, is that an unacceptable deformity is basically what would result if in implant was removed and there was NO BREAST TISSUE. That is to say, if a patient had had a mastectomy and the breast was reconstructed with an implant. If there is breast tissue (ie. after cosmetic augmentation) then whilst we may not like the resulting contour, and we might consider the breast unattractive, that does not constitute an unacceptable deformity.

So, for all of those ladies who have been told that an item number applies for their breast implant revision surgery, all I can say is good luck. Remember, if your surgeon is audited by Medicare (yes, that does happen – quite a lot actually!) and it is determined that your surgery did not meet the item number criteria, then you and your surgeon will be required to pay back the costs of that surgery.

If you have painful capsular contracture, implant malposition, implant rupture, or any other complication of cosmetic breast augmentation surgery performed in the past, then Medicare and your private insurance will cover the removal of those implants. Which is great. Because implant removal will address the medical issues that you have. But they will not (and shouldn’t be expected to) cover the cost of putting new cosmetic implants back in. Because just like the first operation, that is cosmetic surgery.