Insurance Verification for Breast Explant Surgery
While insurers have historically been reluctant to cover breast explant surgery, we are witnessing an improvement in approval rates.
Dr. McCluskey has performed hundreds of explant procedures, and his staff will conduct a complimentary review and submission for coverage to your insurance company. It is essential to understand that we act as intermediaries in this process. Your insurance policy is a contract between you and your insurance provider. Although we can advocate for you, gather necessary documents, and provide supporting evidence, we do not control or determine approval outcomes. If you receive a denial, it will be due to the policies of your insurance provider.
As mentioned, we are seeing improved approval rates, but it is important to note that it is not yet at 100%. You will need to be your own advocate, which may involve time spent on the phone, submitting appeals, and requesting additional documentation.
Insurance Submission Process
1. Insurance Plan Type: It is preferable to have a PPO plan. However, be aware that some PPO plans may exclude coverage for explant surgery. We can contest this exclusion with appropriate documentation, but in some cases, you may need to initiate a prior authorization process to work with your carrier.
2. Carrier Requirements: Insurance carriers may request detailed information about Dr. McCluskey’s extensive expertise and experience in performing explant surgeries, including his commitment to conducting a complete and safe explant and measures taken to detoxify. We can provide supporting letters from medical professionals if needed.
Insurance Checklist
To strengthen your case for insurance coverage, we will require the following:
- A detailed personal account of your journey with breast implants and breast implant illness, including:
- Pain related to breast implants and any complicating factors (e.g., capsule contracture, rupture, breast cancer, Poland’s syndrome, congenital deformities, or asymmetries).
- Documentation of conservative treatments you have attempted, such as:
- Medical therapy
- Massage
- Exercise
- Physical therapy
- Records from healthcare providers you have consulted regarding autoimmune, inflammatory, or pain disorders.
- At least two letters of medical necessity:
- One from Dr. McCluskey
- Another from your primary care physician or another medical provider
- Photographs, a surgical plan, and clinical notes.
By gathering this information, we can work together to improve the likelihood of insurance approval for your breast explant surgery.