You are considering a breast augmentation with prostheses in Paris, You look at the implants, the institute, the price, but the real question is simple: is it reimbursed or not?
Health insurance does not support acts of breast surgery for purely aesthetic purposes. It may reimburse certain procedures when they are coded in corrective surgery (breast malformation, agenesis, major asymmetry, reconstruction after cancer) and that the medical criteria are met.
This article explains everything you need to know about the prior agreement form, medical documents, photos, the CPAM's response, refusals and out-of-pocket expenses.
First, let's review the situations in which breast augmentation is reimbursed.
To check your eligibility for reimbursement and set up your file, make an appointment with the Dr Djian, plastic and aesthetic surgeon in Paris 16.
Breast augmentation may be reimbursed if your breasts have not developed sufficiently after puberty.
Such is the case :
Visually, the breasts are flat or almost flat, the bra doesn't fill out and there's a real absence of breast volume, different from simple “small breasts”.
Surgical intervention can be considered as restorative and should be treated as such, after assessment by the medical officer and subject to appropriate CCAM coding in the following cases :
In these situations, the aim of surgery is not simply to increase volume, but to reconstruct a normal breast shape.
Breast surgery can be performed when the following conditions exist a clear asymmetry between your two breasts. In practice, surgeons often speak of severe“ asymmetry when the volume difference approaches or exceeds one to two cups. There is no single statutory threshold, and the final decision rests with the CPAM's medical officer.
In this context, the French health insurance system may consider that correction (augmentation on one or both sides, sometimes combined with a reduction) is aimed at restoring breast symmetry, which falls within the scope of reconstructive surgery. Slight or moderate asymmetry, on the other hand, remains classified as aesthetic.
When both breasts are extremely underdeveloped, we're talking breast hypotrophy or breast hypoplasia severe bilateral. The figure remains “breastless” while the rest of the body is mature.
In these borderline cases, breast augmentation can be considered as a correction for lack of breast development, rather than a simple comfort augmentation. It is in this precise context that Social Security may consider the procedure reimbursable. may accept coverage. Small breasts with existing volume, even if you consider them insufficient, do not fall into this category.
Breast reconstruction after cancer recognized as ALD, acts of breast reconstruction surgery are covered by Assurance Maladie, subject to coding and approval by Assurance Maladie. This concerns :
In this context, fitting a prosthesis or performing a breast lipofilling or using a flap is not considered an aesthetic procedure, but a step in the treatment of the disease. The aim is to restore an acceptable breast shape and symmetry. reimbursed reconstructive surgery.
Care involves a prior approval request form (formerly “prior agreement”) which is used to show the CPAM that it is a corrective surgery, not an aesthetic request. The important boxes are :
For example:
For you, the challenge is to know what is written as the medical reason, This is exactly what will be evaluated to decide whether or not to accept the treatment. You can ask the surgeon to show you the form and explain each section before sending it.
Standardized photographs are a must The images should be taken from the front, in profile or three-quarter view, with the breasts clear and the light neutral. They must clearly show hypoplasia, malformation, asymmetry or mastectomy sequelae. Without these medical photos, the CPAM cannot objectify the situation.
We add a consultation report (precise diagnosis, cup size, context), the complete clinical examination and, if necessary, imaging tests.
In breast reconstruction, medical and surgical reports are indispensable.
Finally, we include the quote of the plastic surgeon.
The objective A short, clear, readable file, not a pile of papers with no common thread. A plastic surgeon used to these approaches, like the Dr Djian, knows how to get straight to the point.
The request is sent to CPAM (Caisse Primaire d'Assurance Maladie) on which you depend, by registered mail with return receipt to officially date the shipment. To find out which caisse you belong to, go to your Ameli account.
After receipt, the CPAM has a legal deadline of (usually 15 calendar days but may vary depending on the act) to accept, refuse or request additional information. Beyond, the absence of a reply implies tacit agreement, This is an important point to check, along with the date of the acknowledgement of receipt. This is an important point to check with the date of the acknowledgement of receipt.
The CPAM can also call for examination to the consulting physician. He verifies the reality of the hypoplasia, asymmetry, malformation or cancer sequela. This appointment may confirm or invalidate the treatment. Bring your documents with you, and be factual about your experiences and discomforts, but without unnecessary dramatization.
Don't schedule your hospitalization until you have a clear idea of how much your social security will reimburse, especially if the cost of surgery is high.
A large proportion of refusals are due to an insufficiently justified form:
Other refusals may come from the position of the medical advisor, even with a correct file. In this case, the CPAM sees it as nothing more than cosmetic surgery.
Social Security does not reimburse a “comfort” increase disguised as a repair. It is up to the surgeon to formulate precise, coherent and documented medical criteria., on pain of automatic refusal.
If you refuse, start by ask the doctor for a written or oral explanation advice. Sometimes, a new letter from the surgeon, more explicit photos or a medical supplement are enough to reverse the decision.
If the refusal persists, you can enter the CPAM Amiable Appeal Commission, by registered letter. Beyond that point, legal recourse is possible, but not easy.
Before embarking on lengthy procedures, it is often useful to review the situation with an expert plastic surgeon.
Dr Djian, helps you decide whether the administrative battle is realistic, or whether the procedure should be considered purely cosmetic.
When the request is accepted, Social Security can pay for the following, based on the CCAM codes declared:
Hospitalization
The operating theatre
Basic“ fees”
Reimbursable equipment in repair settings
In public hospitals, In principle, care related to breast reconstruction in the context of an ALD is reimbursed at 100 % of the Social Security rate; you are responsible for certain supplements (private room, comfort).
In a private clinic, The reimbursement basis applied by Social Security remains the same: it is still based on the same CCAM procedures and the same conventional tariffs.
Not reimbursed by Social Security:
The why there is often a big difference between the total cost of the procedure and the actual reimbursement by the French Social Security system.
In purely cosmetic breast surgery, You are responsible for all costs.
The quotation must clearly distinguish :
This is the document that allows you to anticipate your budget and send it to your simulation mutual.
In consultation, don't hesitate to ask for an explanation line by line: a serious surgeon won't take offense.
In practice, your complementary health insurance calculates its reimbursements based on the Social Security reimbursement rate. Most mutual insurance companies do not reimburse anything unless specific cover is included in the contract.
With prior agreement, the mutual insurance company can participate :
The “200 %” or “300 %” contracts are calculated on the conventional rate, but not on actual fees. The same statement can therefore cover two quotations very differently.
Before considering an operation date, always send the full estimate to your complementary health insurance company for a written assessment of your out-of-pocket expenses.
Often, the breast reduction is covered when a breast hypertrophy (abnormally large breasts), causing back pain, difficulty dressing and real functional discomfort. Practical information, a removal volume of about 300 g per breast is often used as a benchmark by the French Assurance Maladie to consider breast reduction as reconstructive. This is not an absolute legal threshold, but rather a current medico-administrative criteria.
Below this volume removed per breast, the reduction is most often considered cosmetic.
The cure for breast ptosis alone (sagging breasts but normal volume) is not reimbursed. It may be reimbursed when integrated with a breast reduction repair. Here again, the clinical examination is decisive: volume, impact, approximate weight to be removed.
If you do not no medical criteria, breast augmentation is strictly aesthetic. At this point, the real question is simple: do you assume the total cost of the intervention, without reimbursement or assistance?
For many patients, their self-image and their the psychological weight of the complex far exceeds price of breast augmentation. Breasts deemed “insufficient” can structure years of social avoidance, body insecurity and intimate anxiety. For these women, surgery is not a whim but a definitive solution: successful augmentation brings lifelong relief, Unlike years of compensation or guilt.
“It's dangerous to ”fix" a file by forcing a diagnosis or inventing a pathology. It's fraud, and it's you who suffers the consequences: control, refusal, cancellation of future agreements, loss of medical credibility. It also exposes the surgeon to liability.
It's better an aesthetic project, It's not a question of cobbling together a fragile demand. A serious practitioner will tell you straight out, as Dr Djian does in Paris.
Taking charge of a breast augmentation never depends on a personal desire, but on medically justified cases : absence of mammary gland, marked malformation or reconstruction following cancer. Apart from these indications, the act falls within the scope of a aesthetic purposes, with out-of-pocket expenses and a budget influenced by price of breast prosthesis, the excess fees, the type of’establishment and the cost of breast augmentation.
It's all about medical file solid : photography standardized, precise indication, role of the’surgical procedure, clinical consistency and compliance with repayment conditions.
Before agreeing to a planned operation, you need reliable information to find out whether you are eligible for Social Security reimbursement, or whether the surgery will remain entirely at your expense.
The first consultation with Dr Djian allows you to make a clear choice, to assess what is really a medical necessity, to anticipate non-reimbursed costs and to determine whether or not breast surgery can be covered. A simple way to move forward with facts, not assumptions
No. The CPAM requires a strong medical criteria The most common reasons for this are: severe hypotrophy, agenesis, clear breast malformation or reconstruction after mastectomy. A “small” breast, a complex or a wish for a larger cup size are no justification. In these cases, augmentation is a surgical procedure. purely aesthetic, therefore not reimbursed by social security.
Without reimbursement, you pay for everything: fees, implant, operating room, hospitalization, bra, consultations. The price depends on the surgeon, the type of procedure (with prosthesis or via lipofilling) and the clinic, and is as follows on average between €4,000 and €8,500.
The only way to know what's real price of a breast implant is a detailed quotation given before the procedure. It will cost you a consultation, but at least you'll have a professional opinion and a precise estimate.
Yes, but only when repairing reconstruction after cancer, correction of a major breast alignment or malformation. If fat injection is only used to slightly augment a breast without pathology, is aesthetics and non-refundable. The CCAM code and clinical evidence are mandatory for the application.
The plastic surgeon completes the preliminary agreement, selects the code, The attending physician can describe the discomfort and psychological impact. The attending physician can describe the discomfort and psychological impact. For a square file, a practice accustomed to breast files such as the Doctor Djian in Paris manages from diagnosis to CPAM response.
Dr Jérémy Djian is a plastic surgeon based at 5 square Thiers, near the Victor Hugo roundabout, in the 16th arrondissement of Paris.
He trained in Paris and remains attached to the hospital in the prestigious department of Pr Laurent Lantieri.
