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Breast Implant Removal denials: what the review data shows
Independent reviewers have decided 28 published cases where an insurer denied Breast Implant Removal — and they overturned the insurer 21.4% of the time. A denial for Breast Implant Removal is a starting position, not a final answer.
Published decisions
28
2001–2026
Overturned
21.4%
6 denials reversed
Conditions behind breast implant removal denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Capsular Contracture | 5 | 20% |
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 24 | 20.8% |
Urgent Care Expedited reviews, decided in days rather than weeks. | 4 | 25% |
Typical time to a decision
20 days
Most land between 10 and 21 days
Handled as urgent
17.9%
Expedited when a delay would cause harm
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast implant removal surgery (CPT 19371-RT, 19371-LT, 19328-RT, and 19328-LT) performed by Dr. Lisa Cassileth on 11/02/20.At issue is whether breast implant removal surgery (CPT 19371-RT, 19371-LT, 19328-RT, and 19328-LT) performed by Dr. Lisa Cassileth on 11/02/20 was medically necessary for treatment of the patient’s medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible?
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast implant removal services performed.Findings: The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date of service in question. California law defines “emergency services and care” as “medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility.” A screening examination in an emergency department, and any medical…
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the removal of the right breast implant. Medical literature notes that “Capsular contracture is a troublesome complication of breast implants which may require revision surgery. Capsular contracture initially presents with firmness of the breast and can progress to pain and distortion of the breast shape and volume.” The authors noted that “In a contracted breast, the capsule becomes thick and hard, and shrinks in a way which alters the contour of the breast and the position of the implant.” Medical literature establishes that “The degree of contracture is clinically graded by the grading system.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for breast implant removal surgery. Florin and Halavy report that capsular contracture is a troublesome complication of breast implants, which may require revision surgery, that initially presents with firmness of the breast and can progress to pain and distortion of the breast shape and volume. The authors further explain that when an implant is placed, a fibrous capsule forms around it and while in a normal breast, the capsule is thin and soft, without effect on the appearance of the breast, in a contracted breast, the capsule becomes thick and hard, and shrinks in a way which alters the contour of the breast and the position of the implant.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
How to use this in your appeal
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Breast Implant Removalwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.