I had a consult from a Toronto PS regarding capsulotomy. He indicated that it is not covered by OHIP. Is he correct?

Question

Originally augmentation was done in 2009, capsulotomy done in 2012. I currently have cohesive gel Mentor implants, 400CC, sub muscular. Insertion done below nipple. PS had done capsulotomy at hospital near his clinic., he is no longer practicing so I am not able to go back to him.

Jaime S. Schwartz, MD, FACS · Answer

I appreciate your question.In the US, the capsule removal is sometimes covered by insurance.The best way to assess and give true advice would be an in-person exam.Please see a board-certified plastic surgeon that specializes in aesthetic and restorative breast surgery.best of luck!Dr Schwartz

Rodger Shortt, FRCSC · Answer

Removal of implants and the capsular contracture is an insured OHIP service.  Replacement of implants generally is not.Dr Rodger ShorttPlastic Surgeon Oakville OntarioAssistant Clinical Professor & Director of Cosmetic Surgery Training,McMaster University

Michael J. Weinberg, MD · Answer

Thanks for this questionThe management of a breast capsule is an insured service unless it involves a size increase.I hope this helps

Robert S. Houser, DO · Answer

In general, if you paid to have your implants placed for cosmetic reasons then you are responsible for any revision surgery as well. Insurance will not cover capsule surgery in cosmetic implants.

R. Stephen Mulholland, MD (retired) · Answer

Dear Fitgurl,

Thank you for your clinical post and common question.  The capsulotomy part, that is the tightening
around the implant causing a discomfort or distortion is covered by Ontario
Health Insurance Plan.  Those plastic
surgeons that work in a hospital will get reimbursement fees for the
capsulotomy part or capsulectomy, but in general a new implant insertion is not
covered and there will likely be a fee for this.

For plastic surgeons that work in a private clinic and do not
work in an OHIP credited facility environment generally the
capsulotomy/capsulectomy fees are not charged and the only fee is for the
implant exchange.

I hope this helps clarify what can be a confusing situation
and best of luck.

R. Stephen Mulholland, M.D.

Certified Plastic Surgeon

Yorkville, Toronto

I had a consult from a Toronto PS regarding capsulotomy. He indicated that it is not covered by OHIP. Is he correct?

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Answers (5)

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