Does Medicare cover breast implant replacement?

Does Medicare cover breast implant replacement? There are some situations in which your Medicare plan will pay to replace breast implants. As with all procedures that Medicare covers, the removal of the existing breast implants must be medically necessary. Medicare won’t pay to replace breast implants for cosmetic reasons. The procedure is subject to deductibles and coinsurance.

If you have Medicare Advantage for your health insurance plan, your private insurer will determine what your coverage looks like for a breast implant replacement.

To help you understand health insurance terms, read, How to Buy Health Insurance Guide.

To compare rates for a Medicare plan that covers breast implant replacement, enter your ZIP code now.

What does Medicare cover for breast implant replacement?

Breast implant surgery can be for cosmetic purposes or as the result of a mastectomy due to a serious illness like breast cancer. Learn more about how Medicare covers cancer-related reconstruction in our guide, Does Medicare cover breast reconstruction after a lumpectomy?

If a breast lift or any sort of breast reconstruction surgery has been done and labeled under cosmetic procedures, Medicare will not cover any replacements.

Medicare will cover removal of breast implants even if they were originally placed for cosmetic purposes, as long as the removal is medically necessary. Medicare may not pay to replace the implants unless the original reason for placement was a medical condition. If you’re wondering, Does Medicare cover breast prostheses, they may.

Some of the medical reasons for which the removal of breast implants may be covered are:

• Painful capsular contracture (ICD-10) with disfigurement
• Implant rupture
• Infection
• Implant extrusion
• Interference with the diagnosis of breast cancer
• Siliconoma or granuloma

Your doctor will be able to find out how much of the breast implant replacement is covered based on your personal condition. So even if the original implants were listed as a cosmetic surgery, if you’re health is deteriorating because of them, you may want to ask your doctor if the removal will be covered.

Because Medicare Advantage plans are administered by private companies, they may have different coverage. These plans still cover everything Original Medicare does, but you may have access to additional coverage.

What does a breast implant replacement cost with Medicare?

The cost of surgery to remove and replace breast implants will depend on a number of factors, including the medical reasons for the removal, and whether one or both implants are being replaced. Your health will be considered, as well as the reason for the surgical procedure that you had done.

Both Part A and Part B may be involved in covering the procedure, with Part A covering hospital costs and Part B doctor visits, tests, and outpatient treatments. There are deductibles for Parts A and B, and a 20 percent health care coinsurance for Part B.

Our guide, What are Medicare Supplement Insurance Plans (Medigap)? will help you understand how a Medigap plan may cover breast reconstruction.

Medicare Advantage plans will differ in terms of coverage levels and out-of-pocket costs. It’s best to check with your plan provider to find out what your coverage looks like and what you will need to pay.

To learn more about out-of-pocket costs with Medicare, read, What is the maximum out-of-pocket expense with Medicare?

Case Studies: Breast Implant Coverage and Medicare

Case Study 1: Breast Implant Removal for Medical Necessity

John, a Medicare beneficiary, had breast implants placed for cosmetic purposes several years ago. However, he developed painful capsular contracture, resulting in disfigurement and significant discomfort. Seeking relief, John consulted his doctor who determined that the removal of the breast implants was medically necessary. Medicare covered the cost of the implant removal surgery/

Case Study 2: Medicare Advantage Coverage for Breast Implant Replacement

Sarah, enrolled in a Medicare Advantage plan, required breast implant replacement due to complications arising from a previous surgery. Her private insurer, under the Medicare Advantage plan, determined that the reconstructive procedure was covered. Sarah’s plan covered the breast implant replacement surgery, resulting in minimal out-of-pocket expenses for her.

Case Study 3: Coverage of Breast Implant Removal for Medical Reasons

Mark, who had initially undergone breast implant surgery for cosmetic purposes, encountered implant rupture, causing health issues and disfigurement. Concerned about the potential complications, Mark discussed the situation with his doctor. After evaluating Mark’s condition, the doctor concluded that the removal of the implants was medically necessary.

The Bottom Line: Does Medicare cover breast implant replacement?

Medicare will cover breast implant replacement as long as it fits the “medically necessary” requirements.  You will be responsible for deductibles and coinsurance. Medicare Supplement insurance can help to pay those costs. You’ll want to ask your doctor if the reason you’re looking to have a surgical removal of your implants will be covered under your health insurance policy.

To compare rates on breast implant removal insurance coverage, enter your ZIP code below.