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Insurance Coverage of Breast Implant Removal for Structural Defects in the United States

Michael Ha, MA Cantab MB BChir1, Bashar Hassan, BS2, Nicholas Hricz, BS1, Kevin Zhu, BS1, Ledibabari M. Ngaage, MA Cantab MB BChir1, Sheri Slezak, MD1 and Yvonne M. Rasko, MD1, (1)University of Maryland Medical Center, Baltimore, MD, (2)Johns Hopkins University, Baltimore, MD
Goals/Purpose:

In implant-based breast surgery, structural defects represent some of the most common complications, including implant extrusion, rupture, and contracture. Definitive treatment of structural complications is often implant removal, but this is often accompanied by its own financial burden. As patients often rely on health insurance to cover this cost, we aim to appraise the policy criteria and coverage of breast implant removal after structural complications by insurers in the United States.

Methods/Technique:

A cross-sectional analysis was conducted to assess US insurance policies and criteria requirements for coverage of breast implant removal for contracture, rupture, and extrusion. The top 101 insurance companies were selected based on their state enrolment and market share.

Results/Complications:

Of the 101 insurance companies, 53% (n = 53), 55% (n = 55), and 48% (n = 48) offered pre-authorized coverage for the management of contracture, rupture, and extrusion, respectively. No policies denied coverage of implant removal regardless of the structural defect. In implant contracture, the most common criteria were a diagnosis of Baker’s class III (89%, n = 47) or IV contracture (100%, n = 53). However, an additional criterion of a medically necessary implant was required in significantly more class III cases compared to class IV (n = 34, 65% vs n = 11, 21%, p < 0.0001). In implant rupture, the most common criterion was type of implant: either saline (88%, n = 49) or gel implant rupture (100%, n = 55). A medically necessary implant was required in significantly more saline implant polices compared to gel implants (n = 41, 75% vs n = 12, 22%, p < 0.0001).

Conclusion:

Structural defects are the most common type of complications to arise from breast implant surgery, leading to detrimental clinical and cosmetic outcomes. However, there is a significant discrepancy in how insurers cover the management of these complications based on the indication of the original implant.

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