Does insurance usually cover surgery to correct capsular contracture of implant after radiation?

Question

I have had silicone implants for years. I recently had a lumpectomy, and am starting radiation. I worry about capsular contracture on the radiated breast. If this happens, is my insurance likely to cover surgery to correct it?

Bradley A. Hubbard, MD · Answer

Thanks for your question. There are a lot of variables here that will affect the answer, but the short answer is: yes insurance will cover your surgery. After radiation there is a high probability that something will be necessary to correct your breast shape, size or implant condition. After lumpectomy and radiation, almost all insurance companies will pay for this surgery. best of luck!

Earl Stephenson, Jr., MD, DDS, MBA · Answer

The short answer is yes. You will have capsular contracture if you have a lumpectomy and radiation with an implant in place. Please visit with a board certified plastic surgeon that works with your breast surgeon. You need to know your reconstruction options based on the cancer treatment that will take place.

Richard Baxter, MD · Answer

I am sorry to hear about your diagnosis. You are right to be concerned about capsular contracture with radiation treatment and I hope your physicians discussed this with you in advance as well as how it could be managed if it occurs. I would expect your insurance would cover it but you should ask your carrier directly. Did your team discuss the option of skin and nipple-sparing mastectomy and direct to implant immediate reconstruction as an alternative to radiation?

Connie Hiers, MD, FACS · Answer

Most insurance companies do cover revision surgery for reconstructed breasts. Your doctor may need to send for prior approval request.

David Mathes, MD · Answer

Generally the answer is yes. The impact of radiation on an implant can lead to capsular contracture. If you look at the literature of breast reconstructions that are then radiated the ultimate success rate is 66%. You also should consider replacing your implants at the time of surgery if they are greater than 10 years old.

Thomas M. DeWire Sr., MD (retired) · Answer

arma,This is something to discuss with your surgeon and your insurance company, ahead of time if possible, so there are no surprises.  Unfortunately, Radiation Therapy (RT) does usually cause scar around an existing implant to thicken and tighten (capsule contracture), and correction can be difficult.  Some surgeons recommend removing affected implants before RT, and then replacing them afterwards, using staged tissue expansion, and acellular dermal grafts to break up capsule scar, if necessary.  Federal law (Women's Health and Cancer Rights Act---1998) requires health insurance companies to cover all stages of reconstruction after mastectomy, as well as surgery on the opposite breast to maintain best symmetry. It should give you peace of mind to confirm these concepts and to coordinate this withy your Plastic Surgeon.  I hope that this helps.

Ronald V. DeMars, MD (Retired) · Answer

Insurance contracts vary greatly. I suggest you call your patient advocate at the insurance company for a WRITTEN explanation of your benefits. In general, insurance companies must cover costs of reconstruction done in the case of breast cancer, but since your implants predated the cancer and thus were cosmetic, you really need to get a definite answer from the carrier.

Does insurance usually cover surgery to correct capsular contracture of implant after radiation?

Answers (7)

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