Does Medicare Cover Ruptured Breast Implants? 

Breast implants are not always the result of a cosmetic procedure. Every year in the United States, thousands of women undergo mastectomies to treat breast cancer. During a mastectomy, a surgeon removes all breast tissue from one or both breasts, and in some instances, the skin and nipple are also removed. 

Either after or during a mastectomy, the surgeon can perform a breast reconstruction procedure to restore the natural shape and appearance of the breast(s). The types of reconstruction procedures include breast implants, a natural tissue flap, or a combination of both. 

Regardless of the reason for having breast implants, both saline or silicone implants have outer shells that can tear or leak. Breast implant ruptures are commonly caused by sharp surgical instruments, intense physical pressure, trauma during accidents, or normal aging. 

If you have a breast implant and it seems to have deflated or lost its shape or size, if you feel pain, or experience swelling, you should visit your health care provider immediately to determine whether your implant has ruptured and needs to be removed. 

Does Medicare cover removal of ruptured breast implants? 

Your Medicare benefits may cover surgery to remove your breast implant(s) in certain circumstances. 

To be eligible for this benefit, your physician, who accepts Medicare assignment, must certify that the breast implant removal procedure is medically necessary because of any of these following complications:

• The implant is ruptured, leaking, has failed, or there is an abnormal bump or bulge. 
• The implant has caused you to have an infection or an inflammatory reaction. 
• Your breast implant is causing a complication like siliconoma, granuloma, or capsular contracture which can cause pain or dysmorphia. 
• Your implant is hindering breast cancer diagnosis. 
• Your implant has reached its natural lifespan, and your physician recommends removal for health benefits. A breast implant can last for 10 to 20 years on average, but most people have theirs removed or replaced within 8 to 10 years, depending on complications. 

Even if you’ve had a breast implant procedure for cosmetic purposes that wasn’t covered by your Medicare insurance, you may be eligible for breast implant removal surgery through your Medicare coverage if you have any of the above-mentioned complications. 

If you’ve had breast reconstruction surgery after a mastectomy due to breast cancer, Medicare covers all stages of the reconstruction process. Therefore, if you have a ruptured breast implant that must be removed and replaced, Medicare covers its share of the cost for these services if they are done by health care providers who accept Medicare assignment, and in hospitals or medical facilities that are affiliated with Medicare. 
How does Medicare cover breast implant removal?

Original Medicare Part A (hospital insurance) covers breast implant removal procedures that you have as a hospital inpatient. To qualify for coverage, the hospital must accept Medicare assignment. 

After you pay your deductible for the current benefit period, Medicare Part A covers the costs of the surgical procedure, a semi-private room, meals, drugs, nursing care, medical supplies and equipment, clinical lab tests, and special care units while you’re an inpatient.

If your inpatient hospital stay exceeds 60 days, you must pay the associated coinsurance charge for every day of inpatient care.  

Original Medicare Part B (medical insurance) covers 80 percent of the cost of breast implant surgery if you have the procedure done on an outpatient basis. To qualify for this benefit, your physician or surgeon must accept Medicare assignment, and you must have the surgery done in a medical facility that also accepts Medicare assignment. 

If you’re enrolled in a Medicare Advantage (Part C) plan, your provider must cover your breast implant removal surgery if you meet Medicare’s qualification requirements. 

Depending on the type of Part C plan you have, you may need to use medical providers and facilities, like hospitals, that are listed on your plan’s network of approved providers. Not all plans limit enrollees to using network providers, but if you aren’t sure what restrictions you have, you should contact your provider for details before making health care appointments.