Does OHIP cover my explant surgery?

Does OHIP cover my explant surgery?

Posted on 08/10/2019 in Blog

The answer to this question is a bit complicated. OHIP will pay for breast implant removal sometimes, but how can you know if your particular case is likely to be covered or not?

How do doctors know what OHIP pays for?

To figure out if OHIP pays for something, it’s important to have a little background on how the system works here, so let me pull back the curtain a bit. Doctors in Ontario work on what’s called a ‘fee for service’ basis. This means that we bill the government for each visit with a patient and if we do something procedural we bill for that as well. Each visit or procedure has a specific code and each code billed gets paid at a pre-determined rate. The code and the rate it is paid at can be found in a 747 page document called the “Ontario Schedule of Benefits for Physician Services Under the Health Insurance Act”. A breast reduction, for example, is code R110 which pays $472.15 for the first breast and $401.32 for the second. If a procedure doesn’t have a code, then the government doesn’t pay for it. If there is a code, then OHIP might pay for it. 

Might pay for it?

This is where the answer can get complicated. For some surgeries, like a mastectomy to remove a breast that has cancer, OHIP has a code for it and there is no little asterisk that limits it to certain circumstances. If you have breast cancer, any surgery to remove it (and chemotherapy or radiation) is paid for, full stop. 

For other things, like breast augmentation, there is a note right beside the code that lets us know exactly when it is and is not covered. If it is being done for reconstruction after breast cancer then it’s always covered. If it is being done to one breast to correct a severe asymmetry then it needs to be approved ahead of time on a case by case basis. If it’s being done for any other reason then it’s not covered. 

For other things, the answer isn’t as straightforward and the real answer is hidden elsewhere in the schedule of benefits.

So what about explants?

While there are codes for ‘removal of breast prosthesis’ (a.k.a. explant), capsulotomy and capsulectomy; and there is no note directly beside them describing the limitations, there are comments elsewhere in that giant document that do. To find these comments we have to look 282 pages later, in Appendix D. Here it says two things that relate to when an explant may or may not be covered:

1. The treatment of acute medical or surgical complications resulting from surgery for alteration of appearance and/or function is an insured service whether or not the original surgery was covered.
2. Revision, because of undesirable results, of a surgery, which was originally performed for alteration of appearance, is an insured service only if the original surgery was an insured service 

Allow me to translate from governmentese:

1. Major medical or surgical complications are covered even if they happen because of cosmetic surgery
2. Surgery to correct the results of a cosmetic procedure for any reason other than a major medical or surgical problem is not covered.

While some colleagues feel this is open to a bit of interpretation, to me the answer is pretty straightforward. If you had a cosmetic breast augmentation and you want your implants removed, unless you have BIA-ALCL (the rare cancer associated with textured implants) or a really bad infection that requires the implant to be removed then the removal is elective and the reason they are being removed is because they are “undesired”. In that case OHIP doesn’t pay for your explant. 

What if I have biocell textured implants and I’m worried I’ll get BIA – ALCL?

While it is true that there is an increased risk of getting BIA-ALCL in patients with biocell textured devices, the greatest risk calculated in a study so far is 1 in 3000 women. That works out to a risk of 0.03%, which can also be read as a 99.97% chance of NOT getting BIA-ALCL even if you have these implants. In general, no reasonable plastic surgeon is going to recommend patients remove these implants based on this risk alone. To be honest, no doctor would ever recommend active intervention to prevent any condition that someone has 0.03% chance of getting unless that intervention came with ABSOLUTELY NO RISK (which is NEVER the case for surgery). Whether you should have your implants removed isn’t the point of this blog (it is however, the point of this one). The question for today is: will OHIP pay? 

The answer to me is a very clear NO. While BIA-ALCL is certainly a major complication that OHIP would pay for, being concerned about the risk of it is not. Despite the fact that the likelihood of getting it is obscenely low, some women will still be very stressed about this and might reasonably conclude that OHIP should cover the removal of their implants to relieve that stress. Unfortunately OHIP feels differently. If we take another look at good ol’ Appendix D, we’ll find the following statement: “Emotional, psychological or psychiatric grounds are not considered sufficient reason for the coverage of surgery…except under exceptional circumstances.” What comprises “exceptional circumstances” can be debated, but to put it in perspective any woman who has breasts has a 1 in 8 (12.5%) chance of getting breast cancer yet OHIP will not cover prophylactic mastectomy unless a woman has an increased risk above and beyond that, for example, being a carrier of the BRCA gene. If they are not going to pay for prophylactic treatment of a disease that is much more likely to occur (and actually has a reasonable chance of being fatal) then they are not going to pay for the prophylactic treatment of a condition that is way less likely to occur and is almost never fatal.

What about Breast Implant Illness?

This is not the time or place to get into the discussion about whether I believe breast implant illness (BII) exists, but you can read my full opinion in this blog post. In this case, what matters is whether it is a diagnosis that would count as a “major medical or surgical complication.” Breast Implant Illness is certainly a hot topic, but as of the time I am writing this blog, it is not an official diagnosis that can be made. While there are some very strong opinions from women who believe they are suffering from this condition, there is no evidence linking breast implants to any of the symptoms that have been alleged to result from them. Because of this, there are no specific diagnostic criteria for the condition, and therefore the condition does not officially exist as far as OHIP is concerned. This is not me giving my opinion, this is just the facts. In order for a disease to officially exist there must be a specific set of symptoms caused by it, some sort of explanation for why those symptoms occur, and/or a set of diagnostic criteria that doctors can work with to make a diagnosis. At the moment none of these exist when it comes to BII, just a list of nonspecific symptoms like brain fog, malaise and joint pains that so far we have been unable to link to breast implants through any research study

So how do I know if OHIP will cover MY explant?

If I were to sum things up in one sentence so that patients can know whether they can realistically expect their explant to be covered it would probably be this: “If OHIP paid to put your implants in, then it will pay to take them out. If you paid to put them in, it probably will not pay to remove them.”

If you are looking to remove or replace your breast implants and would like to speak directly with Dr. Plant about your options then contact the office today to schedule your consultation!