Breast implant removal, or explantation, may be covered by Medicare, but coverage is not automatic. The determining factor is whether the surgery is deemed medically necessary rather than cosmetic. Medicare only covers services that are “reasonable and necessary for the diagnosis or treatment of illness or injury.” Removal for personal or aesthetic reasons will not qualify. Securing coverage requires specific medical documentation from a physician detailing a complication directly caused by the implants.
Criteria for Medically Necessary Removal
Medicare will only cover explantation if the implants are causing a documented medical complication. One common qualifying condition is a ruptured or leaking implant. Medicare also covers removal for severe capsular contracture, which is the painful hardening of the scar tissue capsule around the implant. Coverage is granted for Baker Grade III or Grade IV contractures, where the breast is firm, painful, distorted, or cold to the touch.
Other medically necessary circumstances include chronic infection unresolved by conservative treatments, implant extrusion where the device pushes through the skin, or the formation of siliconomas or granulomas (inflammatory reactions to silicone). A diagnosis of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is another clear indication for removal and treatment. Furthermore, removal may be covered if the implants interfere with the diagnosis or treatment of breast cancer, such as obstructing mammogram views.
The physician’s documentation is key to coverage, as it must clearly link the patient’s symptoms and physical findings to the presence of the breast implants. This documentation must demonstrate that the removal is required to treat a disease or injury, aligning with Medicare’s governing statutes. If the original implants were placed following a mastectomy for breast cancer, the Women’s Health and Cancer Rights Act may provide broader coverage for complications.
Coverage Mechanics Across Medicare Parts
Once medical necessity is established, coverage is handled through Original Medicare, which consists of Part A (Hospital Insurance) and Part B (Medical Insurance). Part A covers the costs associated with an inpatient facility stay, such as a semi-private room and nursing care, if the procedure requires an overnight hospital admission.
Part B covers the medical services associated with the surgery, where the majority of explantation costs are billed. This includes the surgeon’s fee, the anesthesiologist’s services, and all outpatient facility services. Since many removal surgeries are performed in the outpatient setting, Part B is the primary payer for professional and facility fees.
Beneficiaries enrolled in a Medicare Advantage Plan (Part C) receive coverage for all the same medically necessary services as Original Medicare Parts A and B. These private plans may have different rules regarding network providers, prior authorization requirements, and cost-sharing structures. Part D covers necessary medications prescribed for post-operative care.
Patient Financial Responsibility and Appeals
Even when removal is covered as medically necessary, patients are responsible for specific out-of-pocket costs under Original Medicare. The patient must meet the annual Part A or Part B deductible, depending on the setting of the surgery. For Part B services, the patient is responsible for a 20% coinsurance of the Medicare-approved amount after the deductible has been met.
Many beneficiaries purchase a Medigap policy, or Medicare Supplement Insurance, which helps cover these gaps, including deductibles and the 20% Part B coinsurance. Patients should contact their provider to confirm estimated out-of-pocket costs before proceeding with the surgery.
If a claim for explantation is initially denied, the patient has the right to appeal the decision through a multi-level process. The first step is typically filing a request for “Redetermination.” A strong appeal relies on robust medical documentation from the physician, including operative reports, diagnostic imaging results, and a detailed letter explaining why the removal meets medical necessity criteria. This documentation must demonstrate that the procedure treats a specific, documented illness or injury, not a cosmetic concern.