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Is future implant replacement covered by insurance?

JulieAggie03 Member Posts: 41
edited August 2020 in Breast Reconstruction

I will be having a BMX in January with TEs. That much I know from discussion with BS as we won't know if I need rads until after surgery. I have also yet to meet my PS, appointment is 12/3. I am pretty sure I will be a candidate for DIEP and am trying to decide if I want that and all the recovery but then I'm done or the "easier" surgery and less recover implant swap. My question is about implant replacement, my BS said they generally have to be replaced every 10 years or so. I am only 34 so I plan on being around for several more decades! Does insurance cover the future replacement of implants or just the initial install?


  • SusansGarden
    SusansGarden Member Posts: 754

    Insurance is supposed to cover it from what I've been told. Assuming you live in the U.S.? I actually talked with my PS about if the technology for fat grafting became easier/more successful, then we could swap out the implants for my fat! :)

    He did also mention that he doesn't necessarily agree with the "swap in 10 years"... as in, if it's not broke, don't fix it. Less trauma to body if they are doing fine? But like you, I was "young" and had mine in at not sure if they'll still be okay 20 years later at 63?

  • trvler
    trvler Member Posts: 931

    I can't imagine the second set being covered. I had implants 30 years ago and I was afraid to consult with a PS about whether they needed to be replaced because I figured they would all say yes for sure. My OB consulted one and they said the same thing Susans said, 'If it aint broke…."

    Well, lo and behold I got cancer and between my mammogram and biopsy I said if it I have cancer I am having the implants taken out. I didn't know about DIEP then. My first BS said the implants would be fine with a lx and rads. My gut told me that wasn't true. Other doctors told me that wasn't true. I asked if rads would hurt the implants and he said probably yes but he could just do another surgery and removed the scar tissue. He was the only doctor out of about 10 I saw that said the implants would be fine. I didn't choose him. It turned out after surgery that one of them WAS in fact leaking. But I never would have known that. I chose DIEP for the reason you describe. I didn't want another surgery and at the end of the day, you don't really know if they are leaking unless you have an obvious break in them.

  • specialk
    specialk Member Posts: 9,221

    Doctors say that they "generally" need to be replaced in 10 years.  The reason for that is because the warranty expires at the ten year point, so the manufacturer is no longer on the hook for the cost of the implant itself if you have a leak or malfunction with the implant after that point.  Implants can be replaced for a variety of reasons, and covered by insurance, if the reason is legitimate and coded correctly by your plastic surgeon.  It is also important to note that autologous flap surgeries are often not a "one and done" surgery, and may require phased surgery or corrections and/or fat grafting, and carry risk of infection, failure, or complications, as do implant surgeries. 

  • SusansGarden
    SusansGarden Member Posts: 754

    On a similiar note... insurance WILL pay for an MRI to check the integrity of the implants every two years because that is the manufacturers recommendation (to cover their arse) So insurance has to pay. At least mine did. Unfortunately I have a super high deductible so I will only be doing it in years that I am close to reaching the deductible. I had it done at year 4 just for peace of mind.

  • summerangel
    summerangel Member Posts: 182

    Yes, insurance will cover replacement, currently the law covers it for the rest of your life. I spoke to my insurance company about this before my surgery.

  • JulieAggie03
    JulieAggie03 Member Posts: 41

    Thank you everyone! So much to think about now! Will be interesting to see what my PS has to say about my options. He is supposed to be one of the best in Dallas.

  • woodstock99
    woodstock99 Member Posts: 80

    may I ask who you are using or if you'd PM me. Starting to interview ps next week. Thanks.

  • IrishEyes39
    IrishEyes39 Member Posts: 5

    I've been wondering about this too.

    My PS said insurance definitely covers replacement, but when I got home I started thinking... if I change insurance companies in 3 years, will the NEW insurance company cover replacements and corrections? From the way I read the law, it just looks like insurance companies that offer coverage for mastectomies have to cover reconstruction (indefinitely). But if my new company didn't cover my original mastectomy, are they still on the hook?

    Confused :/

  • Unbreakable01
    Unbreakable01 Member Posts: 54

    Irisheyes I have the same question. I've had my mastectomy and will get the exchange off my old insurance but I'm starting a new job. To make it easier the first year I'm going to get referrals to all my current doctors under the new insurance. I'm hoping that since they know what's going on the referrals will go through without a hitch and everything covered.

    There were so many other things I had to think about when looking for a new job. Health insurance coverage, being able to go to dr appointments, less stressful work.

  • BethL
    BethL Member Posts: 74

    I don't believe it matters if you have the same insurance when getting reconstruction fixes later on, which implant exchanges could fall under. I had a segmental mastectomy 10 years ago that left my breast small and, well, odd looking. I waited 7 1/2 years to have some reconstruction and my new insurance company covered it without a problem. Another friend of mine...same thing. I think it's one of those things that if your provider relates it to breast cancer, whether current or past, when coding it, they have to cover it

  • Debtn
    Debtn Member Posts: 1

    my insurance company is not paying to replace my 22 year old implants. After reconstruction. They said it was cosmetic. Dah it was cosmetic the first time. I am on my final appeal. I told them I'm sorry I outlived my implants. Any help would be appreciated.

  • bcincolorado
    bcincolorado Member Posts: 4,696

    Has your doctor tried to appeal the decision that they need to be replaced?

  • specialk
    specialk Member Posts: 9,221

    debtn - Since your profile is not filled out I am confused about the order in your post and just want to clarify - did you have bi-lateral mastectomy and implant reconstruction 22 years ago? If so, your plastic surgeon should be able to code surgery to replace the implants as a revision and insurance should cover it. Is the insurance company argument that there is nothing wrong with your current implants so replacing them is cosmetic in their view?

  • moderators
    moderators Posts: 7,884

    Hi debtn, we have the same question as SpecialK. Have you had implants due to breast cancer reconstruction or cosmetic?

  • Artista928
    Artista928 Member Posts: 1,458

    I had my perm implants put in and expanders out a couple months ago. The right is lower than the left, and it's obvious even in a bra. I have Medicare and AARP plan F. Would my PS going in in the summer to lift the right one up to match the left side be covered?? He had said that as long as the word cancer is in the coding that you can change implants and such all you want and insurance must cover it. True?

  • specialk
    specialk Member Posts: 9,221

    artista - I have had expanders placed on three separate occasions (due to loss from necrosis and healing issues), implants placed three separate times as well over the last five years due to skin healing problems - right side twice, left side has had three - all covered by insurance and everything after my initial exchange was coded as a revision. If you have a substantiated issue, it should be covered.

  • Artista928
    Artista928 Member Posts: 1,458

    My issue is the right side hangs lower than the left. PS said he can fix this in the summer. I have MC now. Seems they should cover such revision, even though it's not a health thing?

    Looks like MC does?

    Medicare and breast reconstruction

    October 23rd, 2014 +2

    Thank you for your question. Yes, a bill passed in 1998 mandates insurance coverage for breast reconstruction. Additionally, it also covers any revisionary or balancing procedures on the opposite side to achieve symmetry.

    Matthew H. Steele, MD

    Matthew H. Steele, MD
    Sioux City Plastic Surgeon
    5.0 out of 5 stars 81 reviews

  • Artista928
    Artista928 Member Posts: 1,458

    Seems my ps was wrong? Found this on this site:

    "How your plastic surgeon's office communicates with the insurance company about your surgery can make a major difference, too, says Frank J. DellaCroce, M.D., F.A.C.S., plastic surgeon and co-founder of the Center for Restorative Breast Surgery. The office must use language that clearly indicates it is medically necessary, not just cosmetic. "If you're fixing a reconstructed breast that has become misshapen, for example, or bringing the two breasts into balance, there is a potential for the insurance plan to deny coverage right away and say, 'Well, that's cosmetic.' Instead we might have to say, 'Acquired asymmetry in the breast after mastectomy that was causing a cup size difference that gives difficulty in clothing and function, and she has an overall imbalance that is producing a deformity with respect to symmetry.' When you lay it out like that, then they have a harder time saying well, too bad. It becomes more real."

    So it's a matter of how he codes it to make it look like it's not cosmetic but functional. I can't imagine people being turned down because it's obviously uneven and it shows?

    ETA: I went to my ps website and the billing lady's email is there so I emailed her to find out.

  • lifeisnoteasy
    lifeisnoteasy Member Posts: 7

    Hye ladies

    I know this post was few years ago, I just wondering did anyone do left and right implants? I had mastactomy on my left only now they put under expander and soon implants..and Dr told me he will put implants on my left and right breast, however I worried if this not covered by insurance? What you guys experienced, can you guys please share..


  • Artista928
    Artista928 Member Posts: 1,458

    Yes it's covered. I had bilateral mastectomies in 2015. Left was cancer one. Tissue expanders in both. Perm implants in both 2016. 2017 ps exchanged right implant for symmetrical purposes. Make sure your ps billing dept uses the right codes so they see it's not cosmetic billing.