THE ANSWER:

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Almost all payers, including Medicare/Medicaid DO cover/WILL cover REMOVAL of implants placed for any reason w/ Bakers III+ and/or Rupture.  PAY ATTENTION HERE: they cover ONLY removal of implant/extracapsular material, perhaps capsulectomy/capsulotomy, and NOT revision/replacement UNLESS there’s a personal history of breast cancer or mastectomy for prophylaxis.

 

So…tell that patient we can only get the removal covered and be sure to charge for the replacement!  This also includes lipo, insertion of mesh, insertion of ADM, scar revision, and whatever else you’re planning on doing that isn’t taking the implant out.

 

Reimbursement/Coding

 

19328 (removal intact implant) – .6K unilateral – covered if billed alone.

19330 (removal ruptured implant w/ extracapsular material) – .7K unilateral – includes the above.

19371 (capsulectomy) – .8K unilateral (did I mention I’m rounding up?) – includes ALL of the above.  Don’t bother arguing.

 

*Side note – these cases are killer if you’re out-of-network and have a facility so ignore everything I just said and call us.

 

Medical Necessity

Simple:

1)     This is a breast cancer patient or patient who had a mastectomy for prophylaxis (that was paid by insurance because they met criteria)

2)     This patient has Bakers capsular contracture grade three or higher and/or a rupture

3)     There is no three.  Don’t bother.  Asymmetry – insurance companies don’t care.  Congenital defect – insurance companies don’t care.   Mass not related to cancer – you guessed it…they don’t care.  Callous/insensitive/bullhonky – we agree…but the line is the line.

 

Sales

Same concept as above.  You charge 5K for an aug in Miami and 9K if you think you’re the Disney world of plastics in some major market.  Either way you’re carving out 1.2-1.5K in insurance reimbursement from your case for insurance and your patient is going to have trouble buying why “half the procedure” (e.g., removing the stuff…the other half is putting stuff in) only results in a 25-30% discount for them. 

OK…sell!