Insurers can deny coverage for treatment related to infections caused by breast implants, causing a budding advocacy movement.

“The insurers use the fact that there’s no true medical definition for breast implant illness as an opportunity to try not to pay for it,” said Scot Glasberg, a former president of the American Society of Plastic Surgeons.

Women who have suffered from breast implant illness are asking the FDA for help, but the agency can’t do much when it comes to insurance coverage. Leaking implants can cause a variety of illnesses, but women who need them removed face a series of obstacles from getting necessary screenings to negotiating with insurers to cover the procedures.

The FDA has taken an interest in the problem, however. It held a public meeting on the issue in March. It also flagged two implant manufacturers—Sientra Inc. and Mentor Worldwide LLC—for failing to test their products for safety and effectiveness after they were approved.

Unless breast implants leak, interrupt cancer screenings, or lead to chronic severe pain in the breasts, insurers won’t deem removal medically necessary, according to Diana Zuckerman, who heads the National Center for Health Research. “Since breast implant illness isn’t recognized, it’s not included,” she said in an interview.

Major health insurance providers such as Aetna Inc., cover some breast implant removal surgeries, but they have to be medically necessary, not cosmetic. Aetna also considers the removal medically necessary if the patient has a cancer of the immune system.

The average cost for breast implant removal surgery ranged from $5,000 to $8,000 in 2017 for uninsured patients, according to the National Center for Health Research. The average surgeon’s fee for the procedure was $2,556 in 2018, according to the American Society of Plastic Surgeons. That didn’t include anesthesia, operating room facilities, or other related expenses.

Covering the Test

Jamee Cook, the co-founder of the Breast Implant Victim Advocacy, said it’s also difficult to get coverage for the test to determine if the implant did actually rupture.

“What we’re seeing is some insurances will cover if it’s a confirmed rupture,” she said. “The problem is not all can be confirmed. Another problem is if the implant surgery was cosmetic, most of insurers won’t cover the MRI to see if it did rupture.”

Cook had a ruptured breast implant in 2012, which caused swollen lymph nodes, fatigue, and chronic sinus infections. She ended up with an autoimmune illness and couldn’t get her implant removed until 2015.

Autoimmune illnesses or infections that come from breast implants can affect lymph nodes, lungs, saliva, and tear glands and joints. Silent ruptures, which normally occur in silicone-filled implants, are tears that leave little to no signs or symptoms because the silicone is usually trapped in the tissue that surrounds it.

Surgeons Can Help

Zuckerman said it’s easier to get removal or other treatment covered by insurance if plastic surgeons vouch for their patients and note the symptoms for insurers. That doesn’t always happen during consultations.

“Of, course, doctors can’t tell insurers what to cover, but a statement can say they know that women are suffering and help patients get closer to coverage,” she said

Individually, some plastic surgeons have been willing to work with insurance companies to help patients get covered. But as a whole, she said the industry has been reluctant to push to have breast implant illness recognized as a medical condition.

Claims Sent Back

In his own practice, Glasberg said he notes the best code that describes the illness as it relates to implants and adds it to a bill, but the insurance company usually sends it back.

“In order to [appeal], I have to get documents from whoever the patient has been seeing to prove they’ve been dealing with [breast implant illness] symptoms,” he said. “If these other doctors can weigh in and say it could be related to the implants, that helps.”

Coverage is determined based on the patient’s medical need and circumstances for treatment, the provider and specific plan, who’s providing the treatment and where, and other medical factors according to Cathryn Donaldson, a spokeswoman for America’s Health Insurance Plans, a trade group representing insurers.

“If it is medically necessary, it is generally covered,” Donaldson said. “I would recommend patients reach out to their insurance provider if they have questions about specific benefits and/or their provider network.”

Zuckerman said women can build a better case to avoid insurance denial.

“We found that women were only asking about the symptoms associated with [breast implant illness] because that was more severe to them, even though they had leaking implants or pain,” she said. “They have to focus on and talk about what insurance companies care about covering.”

Moving Forward

Glasberg said an FDA study on women suffering from breast implant illness will help medically define it and could even help insurers see the medical need for treatment.

“The FDA basically is in the business of studying patient safety, so that’s probably the only direction they can go,” he said. “There are many symptoms.”

He said plastic surgeons could also be a resource in tightening the “loosely defined” symptom list and “come up with a diagnosis code”

American Society of Plastic Surgeons President Alan Matarasso said women seeking implants should find a surgeon that participates in the National Breast Implant Registry, which tracks a number of factors related to the implant, including complications. Plastic surgeons and implant manufacturers then can see how these products fare.

“A patient may get implants in when they’re 25 years old and move around,” Matarasso said. “A plastic surgeon may die or stop practicing. The patient may even have implants and forget about them in 20 years, but if you need something or something goes wrong, there’s access to information.”