Insurers Denying Coverage For Women Fighting Infections From Leaking Breast Implants

Spencer Law Group April 18, 2019

Insurers can deny coverage for treatment related to infections caused by breast implants, causing a budding advocacy movement.

“The insurers use the fact that there’s no true medical definition for breast implant illness as an opportunity to try not to pay for it,” said Scot Glasberg, a former president of the American Society of Plastic Surgeons.

Women who have suffered from breast implant illness are asking the FDA for help, but the agency can’t do much when it comes to insurance coverage. Leaking implants can cause a variety of illnesses, but women who need them removed face a series of obstacles from getting necessary screenings to negotiating with insurers to cover the procedures.

The FDA has taken an interest in the problem, however. It held a public meeting on the issue in March. It also flagged two implant manufacturers—Sientra Inc. and Mentor Worldwide LLC—for failing to test their products for safety and effectiveness after they were approved.

Unless breast implants leak, interrupt cancer screenings, or lead to chronic severe pain in the breasts, insurers won’t deem removal medically necessary, according to Diana Zuckerman, who heads the National Center for Health Research. “Since breast implant illness isn’t recognized, it’s not included,” she said in an interview.

Major health insurance providers such as Aetna Inc., cover some breast implant removal surgeries, but they have to be medically necessary, not cosmetic. Aetna also considers the removal medically necessary if the patient has a cancer of the immune system.

The average cost for breast implant removal surgery ranged from $5,000 to $8,000 in 2017 for uninsured patients, according to the National Center for Health Research. The average surgeon’s fee for the procedure was $2,556 in 2018, according to the American Society of Plastic Surgeons. That didn’t include anesthesia, operating room facilities, or other related expenses.

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