Implant replacement reimbursed by insurance?

If you had breast augmentation with implants more than 10 years ago, it’s wise to have your breast implants checked. Although breast implants are getting better and better, and therefore need to be replaced less, there’s a chance you may need to replace or remove the implants.

In most cases, an implant change is not covered by your health insurance company. But there are some exceptions where breast surgery is partially reimbursed by your health insurance company.

Reimbursement for excessive capsular formation and capsular contraction

If there is excessive capsular formation and capsular contraction, your health insurance may cover part of the surgery. Whether you receive compensation depends on the degree to which capsular contracture has occurred. The Baker classification is often used to indicate the extent of capsular contraction. The Baker classification consists of 4 grades:

  • Baker 1 – there is no abnormality. Encapsulation occurs in all patients with breast augmentation with implants.
  • Baker 2 – the breast feels a little hard, but the natural shape is retained.
  • Baker 3 – the breast feels hard and deformation is visible. There is no pain yet.
  • Baker 4 – the breast feels hard, distortion is visible and the breast is painful.

Basic insurance reimburses* the cost of removing breast implants only if there is a medical necessity for doing so. There’s a medical necessity in the following cases:

  • Capsular Baker 4,
  • A demonstrable leakage (by ultrasound or mammography) of the silicone implant, or
  • A persistent or recurrent infection due to the implants.

Thus, from the basic insurance, the replacement or placement of new implants is not covered.

Combination of insured and uninsured care

Merely removing the breast implants, without replacement or padding, is usually not desired. Women often choose to remove the old implants and have new implants placed during the same surgery. An alternative to implants is breast augmentation with your own fat (lipofilling).

New implants, their placement and/or filling the breast with your own fat is almost never covered by insurance.

At MOOI Clinic, we offer you the unique opportunity to have your treatment qualify (in part) for reimbursed care. At the hospital, the plastic surgeon can request an authorization from your health insurance company. If the health insurance company approves the authorization, insurance will cover the removal of the implants. The placement of new dentures or lipofilling treatment is not covered.

What to do.

  • Consult your health care policy.
  • Think you qualify for insured care? Then ask your family doctor for a referral to the plastic surgeon at the hospital.
  • Referred by the family doctor? Contact the hospital. Treatment with one of our plastic surgeons takes place in hospitals: Zuyderland in Sittard or Heerlen, the MUMC+ in Maastricht, or the VieCuri in Venlo.
  • No referral or approval authorization? Then you’re not eligible for (partially) reimbursed care. In this case, we can perform the entire treatment at MOOI clinic. In this case, contact MOOI Clinic.

health insurance reimbursement breast implants

* Consult your health care policy. To qualify for reimbursement, your situation must meet certain criteria. In addition, there may be maximum reimbursement and payment of the mandatory deductible.