Will Medicare Cover my Breast Implant Removal?

Explant Surgery – Will Medicare Cover My Breast Implant Removal?

Medicare and Private Health may contribute towards a portion of the cost of your Breast Implant Removal if you meet the strict criteria.

What is a Breast Implant Removal Procedure?

Breast implant removal procedure is performed with the purpose of removing breast implants that have been placed during a breast augmentation procedure or a breast reconstruction procedure. You can have your implant removed and have a new one of the same size or a different size placed instead. This is often done as breast implants only last for about 10 years to 30 years and then need to be removed and replaced. Patients are always informed of this in their initial consultation leading them to ask, “if something goes wrong, will Medicare cover my breast implant removal?” Let’s look at the reasons for breast implant removal and the scenarios where Medicare may contribute.

Breast implant removal surgery may be performed if you are not satisfied with the appearance of your breast after the surgery. The procedure may also be performed if your implant has ruptured or leaked into the implant pocket.

If you had opted for large breast implants and have naturally small breasts, then you may experience neck, shoulder, and back pain due to the size and the weight of the implants. In this case, you can have your breast implant removed permanently or have smaller implants placed instead.

Breast implant removal surgery may also be an option for those who are worried about the medical side-effects of having a breast implant. This procedure may also be done if the scar tissue in your breast has tightened and is causing a significant amount of pain.

You can undergo a breast implant removal surgery only if you are physically healthy and a non-smoker. You should only undergo this procedure for yourself if you have realistic expectations and goals from the surgery.

When removing the breast implant, Dr Doyle will also need to remove the scar tissue (capsule) that often forms around the implant. In some cases, your surgeon may not remove this scar tissue as it is quite soft and seems harmless but it has the ability to harden and become quite painful. This is why it is always recommended that the scar tissue be removed along with the implants.

In those patients that have implants with a textured surface, there is a low risk of a type of cancer called a lymphoma (ALCL) that can grow in the scar tissue. For this reason, Dr Doyle ALWAYS removes the complete capsules when he is removing the implants. This is done using an En Bloc Technique.

Likewise in those patients suffering from Breast Implant Illness (BII), an eEn Bloc removal of implant and capsule removes all the issues associated with the breast implant insertion and may lead to better recovery rates in this condition.

The breast implant removal surgery, like any other surgical procedure, has certain risks and complications associated with it that you should discuss with your surgeon in detail before deciding to undergo the procedure. Some of the common risks of the procedure include bleeding, infection, and reaction to anesthesia.

Book a consultation now to find out more about the procedure.

Will Medicare Cover My Breast Implant Removal Procedure?

Medicare is a national insurance program that helps citizens with their medically necessary procedures by subsidising the cost of the procedure. However, it does not cover any procedure that is not medically necessary such as a cosmetic surgery procedure performed purely for the purpose of improving your physical appearance and body aesthetics.

Breast Implant Removal procedure can be both a medically necessary procedure and a cosmetic procedure depending on your expectations and the specifics of your case. If you are undergoing breast implant removal along with new implant placement with the sole purpose of improving your physical appearance, then chances are Medicare will not cover your procedure.

However, if you need to have your implant replaced after removal, because if you didn’t, you would have a significant deformity of the breast, or because the implant was initially placed due to a developmental abnormality or breast cancer, there is a high probability that your procedure will have a Medicare rebate.

Your breast implant removal surgery may also have a Medicare rebate if it has become medically necessary for the implant to be removed due to cancer risk or other medical conditions. There are eligibility criteria set by Medicare that needs to be met for your breast implant removal surgery to be considered medically necessary.

Eligibility Criteria for a Medicare-covered Breast Implant Removal Procedure

For your breast implant removal procedure to be partly funded by Medicare, you need to meet one of the following criteria:

• Your implant has resulted in capsular contracture that is causing extreme pain and disfigurement
• Your implant has ruptured and leaked into the surrounding structures, causing deformity of the breast
• There is an infection of the implant
• Your implant is extruding through the skin
• Your implant is interfering with the diagnosis of breast cancer
• There is a siliconoma (silicone filled mass under your skin) or granuloma present
• You are suffering from breast implant illness, which is an illness similar to autoimmune disorders such as connective tissue disease or fibromyalgia present in women with breast implants

If you meet the criteria above and can provide evidence in the form of documentation signed by your doctor, then Medicare may contribute towards the funding of your breast implant removal surgery. You should get the evidence from your primary care physician, plastic surgeon, and any other doctor on your surgical team. The more the merrier. You should also have photographic evidence of any deformity that may be present and you should submit that along with the documentation to Medicare for a Medicare rebate.

What Medicare Item Numbers Cover a Breast Implant Removal Procedure?

• 45542

BREAST RECONSTRUCTION (unilateral), the following mastectomy, using tissue expansion – removal of tissue expansion unit and insertion of the permanent prosthesis (Anaes.) (Assist.)

• 45548

BREAST PROSTHESIS, removal of, as an independent procedure (Anaes.)

• 45551

Breast prosthesis, removal of, with excision of at least half of the fibrous capsule, not with the insertion of any prosthesis. The excised specimen must be sent for histopathology and the volume removed must be documented in the histopathology report (Anaes.) (Assist.)

• 45553

Breast prosthesis, removal of and replacement with another prosthesis, following medical complications (for rupture, migration of prosthetic material or symptomatic capsular contracture), if: (a) either: (i) it is demonstrated by intra-operative photographs post-removal that removal alone would cause unacceptable deformity; or (ii) the original implant was inserted in the context of breast cancer or developmental abnormality, and (b) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes (Anaes.) (Assist.)

• 45554

Breast prosthesis, removal and replacement with another prosthesis, following medical complications (for rupture, migration of prosthetic material or symptomatic capsular contracture), including excision of at least half of the fibrous capsule or formation of a new pocket, or both, if: (a) either: (i) it is demonstrated by intra-operative photographs post-removal that removal alone would cause unacceptable deformity, or (ii) the original implant was inserted in the context of breast cancer or developmental abnormality, and (b) the excised specimen is sent for histopathology and the volume removed is documented in the histopathology report, and (c) photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes (Anaes.) (Assist.)

An important thing for you to keep in mind is that the MBS item numbers mentioned here are subject to change and you should check the online MBS directory for updated MBS item numbers for your procedure.

What to expect when applying for a Medicare Rebate?

If you are applying for a Medicare Rebate, Dr Doyle’s office will take all the necessary photographs and complete all necessary documentation on your behalf.

You will need to ensure that you meet the eligibility criteria prior to the surgery so as to have no issues later on when you need to be reimbursed. This is especially important as Medicare often does not issue pre-authorisation for any procedure. Medicare only pays for the procedure after the surgery has taken place which is why it is important for you to have all your papers and evidence sorted out to ensure that you will be receiving a Medicare rebate.

It is important to note that there will be out of pocket costs including hospitalisation costs, anaesthetist fees and surgeons fees even with a Medicare rebate. You should be prepared for this and discuss any potential hospital stay and extra fees with your surgeon prior to the surgery to avoid any unwanted surprises.

Associated Procedures that are covered by Medicare

Breast implant removal procedure is a surgical procedure that may be covered by Medicare if you meet the eligibility criteria and have pre-authorization. However, before having a breast implant removed, you need to undergo MRI scans which help your surgeon visualize the breast implant. These MRI scans may be funded by Medicare under the following MBS Item Numbers:

• 63547

MRI scan of both breasts for the detection of cancer, if (a) a dedicated breast coil is used; and (b) the request for the scan identifies that: (i) the patient has a breast implant in situ; and (ii) anaplastic large cell lymphoma has been diagnosed. NOTE: benefits are payable once in a patient’s lifetime

• 63548

MRI scan of both breasts for the detection of cancer, if (a) a dedicated breast coil is used; and (b) the request for the scan identifies that: (i) the patient has a breast implant in situ; and (ii) anaplastic large cell lymphoma has been diagnosed. NOTE: benefits are payable once in a patient’s lifetime

• 63501

MRI – scan of one or both breasts for the evaluation of implant integrity where: (a) a dedicated breast coil is used; and (b) the request for the scan identifies that the patient: (i) has or is suspected of having a silicone breast implant manufactured by Poly Implant Prosthese (PIP); and (ii) the result of the scan confirms a loss of integrity of the implant (R)

• 63502

MRI – scan of one or both breasts for the evaluation of implant integrity where: (a) a dedicated breast coil is used; and (b) the request for the scan identifies that the patient: (i) has or is suspected of having a silicone breast implant manufactured by Poly Implant Prothese (PIP); and (ii) the result of the scan does not demonstrate a loss of integrity of the implant (R)

• 63504

MRI – scan of one or both breasts for the evaluation of implant integrity where: (a) a dedicated breast coil is used; and (b) the request for the scan identifies that the patient: (i) has or is suspected of having a silicone breast implant manufactured by Poly Implant Prothese (PIP); and (ii) presents with symptoms where implant rupture is suspected; and (iii) the result of the scan confirms a loss of integrity of the implant (R)

• 63505

MRI – scan of one or both breasts for the evaluation of implant integrity where (a) a dedicated breast coil is used; and (b) the request for the scan identifies that the patient: (i) has or is suspected of having a silicone breast implant manufactured by Poly Implant Prothese (PIP); and (ii) presents with symptoms where implant rupture is suspected; and (iii) the result of the scan does not demonstrate a loss of integrity of the implant (R)

Medicare and Breast Implant Removal Frequently asked Questions

What will happen to my breasts after I have my implant removed?

After your breast implants have been removed, your breasts will deflate and go back to their natural appearance. However, they may be saggier than before, particularly if you have had large heavy breast implants, and the perkiness of your breast may be lost. The results of the implant removal surgery depend on various factors like the implant size and the size of your natural breasts. You should discuss the results of the procedure with your surgeon before undergoing the surgery.

Is a breast lift important after breast implant removal surgery?

If your breast implants were large and your natural breasts are small, then your skin had to stretch significantly to cover the implants. After the implant is removed, the stretched skin may sag and make the breast look droopy. In this case, a breast lift can make your breast taut and firm again.

What are the signs of breast implant illness?

Breast implant illness is a serious medical condition that may present as chronic fatigue, joint pain, muscle aches, skin irritation and rashes, sleep disturbances, and problems with concentration and memory. Breast implant illness may also worsen existing anxiety and depression. It may also result in hair loss and dryness of the mouth and eyes.

These symptoms may appear at any time after the implant placement surgery and may be resolved by the removal of the implant.

“My personal experience is that the majority of patients with this condition has a significant improvement in symptoms when the implants and their capsules are removed,” says Dr Mark.

Related Blogs

• Will Medicare Cover My Breast Implant Removal in Queensland?
• What Is Breast Implant Malposition and Breast Implant Flipping?
• Why Get an En Bloc Technique Breast Implant Removal
• What Is Breast Implant Illness? – a Social Media Phenomenon or a Real Condition?
• Nipple Reshaping and Areola Reduction: Who Is the Ideal Candidate, Benefits, and More 
• Combining Plastic Surgeries: When Can Multiple Procedures Be Combined?

Further Medical Reading

• Breast Implant Removal Candidates – American Society of Plastic Surgeons
• What Happens When You Have Breast Implants Removed – AEDIT