Does Medicare Ever Cover the Cost of Breast Implants?
Medicare Benefits Solutions
Oct 7, 2022
A breast implant refers to a medical device, AKA a prostheses, that is surgically placed under chest muscle or breast tissue. You may decide to undergo breast implant surgery as part of reconstructive surgery following a mastectomy. Or you may choose to have augmentation mammoplasty, an elective breast surgery procedure that increases breast size.
If you are 65 and eligible for Medicare, or under the age of 65 and qualify for Medicare due to a long-term disability, you may wonder if your insurance will help cover the costs of plastic surgery procedures.
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Does Medicare Cover Plastic Surgery?
Medicare requires prior authorization for surgery and will evaluate if the procedure falls under the category of cosmetic surgery or medically necessary surgery.
According to the National Center for Biotechnology Information, breast augmentation, plastic surgery performed to enhance breast size, is “one of the most commonly performed plastic surgery procedures in the United States.” Though breast augmentation can be performed through fat transfer, the more common approach is using silicone or saline breast implants.
As a general rule, Medicare covers medically necessary inpatient and outpatient surgery. However, Medicare Part A and Part B coverage does not include plastic surgery performed solely for cosmetic purposes. However, you may be eligible if plastic surgery is done to repair an injury caused by an accident or improve the functionality of a body part.
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Are Breast Implants Covered by Insurance?
Most insurance companies will decline claims for cosmetic surgery. If you have to pay out-of-pocket for breast augmentation Medicare or other insurance does not cover, expect the cost to start around $4,500 plus other fees, according to the American Society of Plastic Surgeons.
When calculating your total cost, remember to take into account the surgeon’s fee, anesthesia, facility fees, medical tests and prescription medications. These costs vary throughout the country.
The Mayo Clinic explains why some women choose elective breast augmentation even if not covered by insurance:
- Self-perception of small or asymmetrical breasts, causing discomfort wearing garments that don’t seem to fit right
- Reduction in breast size after a pregnancy or considerable weight loss
- Uneven breasts as a result of surgery or other conditions
- Personal decision to boost self-confidence
Every individual’s journey leading to plastic surgery is unique and should be respected. However, insurance companies generally restrict benefits for elective surgical procedures.
Does Medicare Cover Breast Implants?
If your doctor certifies that a mastectomy is medically necessary to remove cancerous tissue, you may be eligible for breast augmentation Medicare benefits following the mastectomy. Coverage includes the cost of implanted breast prostheses and a post-surgical bra.
Breast implant surgery that is covered by Medicare will fall under Part A (inpatient) or Part B (outpatient), depending on where your surgeon performs the procedure. Part A is hospital insurance that covers procedures performed once you are formally admitted as an inpatient to a hospital or skilled nursing facility. Part B is medical insurance that covers procedures, treatment and care you receive in an outpatient setting.
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Medicare Breast Surgery Copays
The Centers for Medicare and Medicaid Services provides guidelines for “reconstructive surgery performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease.”
Here are just a few of the Medicare billing codes used for common breast reconstructive surgical procedures :
- Code 19325 – breast augmentation with implant
- Code 19328 – removal of intact breast implant
- Code 19330 – removal of ruptured breast implant
- Code 19340 – insertion of breast implant on same day of mastectomy
- Code 19342 – insertion or replacement of breast implant on separate day from mastectomy
- Code 19350 – nipple/areola reconstruction
- Code 19357 – tissue expander placement in breast reconstruction
The Medicare Procedure Price Lookup tool shows the national average prices based on payments and copayments. Out-of-pocket estimates for breast sugery will vary, depending on the location and facility. The estimates include facility and doctor fees, but remember to add in fees for the services of any additional doctors.
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Potential Risks Associated with Implants
The Federal Drug Administration (FDA) has approved breast implants filled with either saline (sterile salt water) or silicone (gel) but cautions women about potential risks and complications, including the following:
- Pain and changes in sensation in the nipple or breast, such as increase or decrease in feeling that can impair sexual responsiveness
- Capsular contracture, scar tissue forming around the implant and possibly squeezing the implant
- Inability to produce milk for breastfeeding due to removal of breast tissue and milk-producing glands
- Silent ruptures, asymptomatic ruptures that cause the gel of silicone gel implants to leak through a hole or tear in the implant shell
In 1992, the FDA restricted the use of silicone-filled implants done for the purpose of cosmetic enhancement, though medically necessary reconstructive implants continued. The FDA removed the restriction in 2006 but recommends an MRI screening every two years.
Like most things, breast implants are not expected to last a lifetime. The longer you have had implants, the higher the chance of complications and the need for implant removal.
Does Medicare Pay for Implant Removal?
Reasons you may need your breast implants removed range from elective surgery based on personal preference to complications like infection, damage, or pain. If the reason is based on medical need, you may be eligible for Medicare benefits.
When you discuss your condition and options with your surgeon, be sure to ask about scar tissue surrounding the implant (scar capsule). Your surgeon may want to remove only the implant and not the scar capsule. This approach may reduce the risk of complications because there is less cutting involved.
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Learn More About Breast Augmentation
Here are a few sources for researching breast augmentation options and regulations to help you prepare questions for your doctor as part of your medical consultation:
- American Society of Plastic Surgeons
- The American Board of Cosmetic Surgery
- U.S. Food & Drug Administration
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