Coverage for Breast Explant Surgery Was Denied – Kantor & Kantor Stepped In and Got the Denial Overturned

It’s a common story shared by an increasing number of women. They received breast implants and after a period of time they started getting sick.  While we do not know the exact number, we know that the largest Facebook Group has grown to nearly 83,400 members, with an increase of more than 5,200 in the last 30 days.

A client, whose name is being kept anonymous to protect her privacy, contacted Kantor & Kantor recently for help with an insurance denial. The woman was in failing health and had been experiencing severe medical complications dating back to 2012 after receiving breast implants. The woman referred to her condition as “breast implant illness.”

After consulting with her primary care physician, the woman underwent a bilateral breast MRI which revealed findings consistent with intracapsular rupture in the left breast. Shortly after, she was referred to a plastic surgeon who recommended bilateral breast capsulectomy and implant removal. The procedure, referred to as explant surgery, involves the removal of the implants and the surrounding capsules (or scar tissue).

The woman’s plastic surgeon submitted a pre-authorization request to the insurance company. The request was denied on medical necessity grounds. The woman appealed, but benefits continued to be denied through the insurance company’s internal and external appeals process.

Recognizing that the insurance company’s denial was improper, Kantor & Kantor quickly took action and as a result of their efforts the insurance company overturned their denial and authorized the explant surgery as medically necessary.

Unfortunately, most women who want their breast implants removed for medical reasons and want their health insurance to cover it, will be denied coverage.

If you or someone you know has been denied coverage for breast removal surgery, please contact Kantor & Kantor at 888-569-6013 or use our online contact form  for a free consultation.

Kantor & Kantor would like to thank our friends and colleagues Mark DeBofsky and Marie Casciari of DeBofsky Sherman & Casciari P.C. for their help with this case.

 

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