Cosmetic or medical?

[SLuskin]

I would like to know how others view this expense - a woman had cosmetic breast implants in the past, but apparently they became infected and needed to be removed (and replaced?). Of course, it is the wife of the first name partner in a law firm. Any help would be greatly appreciated. Thanks.

[JanetM]

I would vote medical if the implants had to be removed due to the underlying medical condition (infection). Would say the replacement would be covered since the removal was done for medical reason.

[Guest FAQ]

I have the same issue. The individual had a ruptured breast implant removed and has requested reimbursement from the health FSA. We will probably have the FSA reimburse the expense of the removal.

I have not found anything on point in rulings or information letters, but removal of a ruptured implant would appear to be a medical expense. It seems to fit the §213(d)(1) definition of medical care (e.g. it affects a structure or function of the body and may prevent disease caused by the ruptured implant).

It should not fit the definition of "cosmetic surgery" under §213(d)(9). It was not done for cosmetic reasons (although the original implant likely was). Removal of an implant arguably would not improve appearance (we do not know whether the individual received a replacement implant, although we do know that she has not requested reimbursement for a new one). Finally, removal of the ruptured implant would probably "meaningfully promote the proper function of the body or prevent or treat illness or disease."

Thanks in advance for any thoughts.

[Guest JerseyGirl]

I would approve the removal, as the infection caused by the implant rupturing has caused the procedure to be medically necessary, but would not reimburse for replacement unless the original implants were medically necessary. Had they been done to repair damage (fire, freak accident, etc) or to correct an abnormality, then, and only then , would I consider reimbursing for replacement. I would want lots of back-up documentation on it though.

[Guest b2kates]

I agree with Jersey Girl's analysis.

[Alf]

Is this an FSA question?? I didn't think partners could participate?

[Guest FAQ]

Thanks for the input. I have since discovered that the cost for the procedure includes replacement of the ruptured implant. I am hesitant to recommend that the plan reimburse the portion of the cost attributable to the replacement implant.

Presumably the replacement implant is for cosmetic reasons (in order to maintain a symetrical appearance?). I don't believe the replacement implant would be needed "to ameliorate a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting froman accident or trauma, or disfiguring disease," as set forth in Code §213(d)(9)(A). There may be a deformity without the new implant, but the deformity is not due to disease or trauma. It is because the individual had the initial cosmetic surgery.

Also, the replacement implant would not promote the proper function of the body or prevent or treat illness or disease. Arguably it could exacerbate or promote illness or disease, if it were to rupture again.

[GBurns]

Shouldn't the whole problem, of whether to cover or not, be moot, in light of the issue raised by Alf?

If partners cannot participate in an FSA, as questioned by Alf, and this is an FSA, then no reimbursement is possible because there should be no coverage of an ilegible plan participant in the first place.

[mbozek]

What if the employer is a Professional corp and the partner is a shareholder of the PC? Anyway where does FAQ post apply to a partners wife?

[Guest FAQ]

Please allow me to clarify. Unlike the original post, our situation does not involve a partner's wife or business owner in any other capacity. Our situation involves a regular employee who participates in the FSA.

However, we face the same issue from a deductibility standpoint (whether the full cost of the replacement is reimbursable through an FSA, or just the costs relating to the removal of the ruptured implant).