Capsular Contracture - Does Insurance Cover it?

Question

Does health insurance cover capsulectomy? And if it does, what grade does it need to be?

Ryan Neinstein, MD, FRCSC · Answer

Depends where you are, in Canada capsular contracture is consdered a coverred benefit by the government as it casused pain

Asif Pirani, MD, FRCS(C) · Answer

It depends on the insurance company and where you live.  In Canada, Grades 4/5 are covered.  Ask a PS in your geographical area.Best,

Eugene Kim, MD · Answer

Some insurance companies will cover capsular contracture if it is causing symptoms like pain (Grade IV).  It often requires approval from the insurance company prior to surgery.  I recommend seeing a plastic surgeon for consultation who can check with your insurance company.

Jourdan Gottlieb, MD · Answer

Most carriers exclude coverage for any complications of cosmetic procedures. When it is covered, it is usually limited to grade 4 CC, and these are quite unusual with implants placed during the last 15 to 20 years. Your plastic surgeon would be the best source of advice. After an exam if surgery is recommended, a letter of preauthorization would be written to the insurer.Thanks for you question, all the best.

George C. Peck, Jr, MD · Answer

Every insurance company is different and every policy within the company may be different.Some insurance companies cover the procedure but of course, it must be precertified.My office is in West Orange.Best wishes

C. Bob Basu, MD, MPH, FACS · Answer

Some insurance carriers can cover this but unfortunately more and more insurance companies will not because they deem the treatment as cosmetic (not medically required).  Please contact your insurance carrier to see if  this is a covered benefit.  Also visit with a board certified PS to learn more about your options. best wishes,Dr. Basu

Scott R. Brundage, MD · Answer

All medical insurance policies have different benefits and coverages. In the case of capsular contracture it usually is covered if the patient is symptomatic (having pain). This would be classified as a Baker Grade IV. The best thing to do is to discuss this with your surgeon and have he or she write a letter for preauthorization to your insurance carrier. This would be reviewed and a determination of coverage would be given.

Capsular Contracture - Does Insurance Cover it?

Answers (7)

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