Will insurance cover Capsular contraction at Grade 4 ?

Thank you for your question and I am sorry to hear of your capsular contracture.  I would recommend reaching out to your insurance company to see if its a covered procedure.  They will want to know if your breast implants were placed for cosmetic or reconstructive purposes as most cosmetic patients will not have contracture typically covered.  Hope this helps.

It all depends.If it was for reconstructive purposes, probably. If it was for cosmetic reasons originally, then maybe.Some plans I have seen say they will cover contractors in a cosmetic breast surgery:Grade III and IV only, or some say just IVBoth silicone and saline, or maybe just siliconeOnly if there is a ruptured silicone implantIf they do, it is usually only the removal of the implant and scar tissue, and rarely, if ever, have I seen a plan cover the replacement, or a new implant, which many surgeons would recommend.  

If your capsular contracture is causing distortion of breast shape and pain then treatment is considered medically necessary. If your original surgery was reconstructive and covered by insurance then almost certainly your insurance company should cover the treatment of this condition. However if the original surgery was cosmetic then you should go through the process of preauthorization as some insurance companies do not cover the treatment of conditions which are a sequelae to cosmetic surgery. You should also look into the possibility of any financial assistance from the implant manufacturer. I think the latter is highly unlikely as capsular contracture is a known complication of breast implant surgery, inherent to the presence of an implant and not any defect in the product.

The definition of grade 4 capsular contracture is that the contracting scar capsule is distorting the shape of the breast and is causing pain.  If the problem is following implant reconstruction following treatment of breast cancer,it is almost always covered.  As stated by others, some insurance carriers cover the treatment of it following cosmetic surgery implants.  Some implant manufacturers have warranty coverage for capsular contracture.

The answer is: maybe. It really depends on a number of factors - your insurance coverage, specifically your benefits for your exact plan. Coverage varies significantly from plan to plan even in the same company. You would want to first call your insurance company and ask if your policy covers procedure codes (CPT) 19371 (capsulectomy) or 19370 (capsulotomy) and see if they will give you the requirements for coverage - which they may not. Additionally you would have to have some documented history via your primary care doctor (preferably) which demonstrates your current symptoms which are probably pain, tightness etc., which is unrelieved by a conservative measures. A formal referral to a board certified plastic surgeon would be recommended.Provided your plastic surgeon is in agreement with the diagnosis, he or she will have to send a letter and photos documenting your history and physical findings and see if you qualify for coverage. As you can see this is not an easy task and even if you have all your ducks in a row, there's no guarantee that you will obtain coverage. Best of luck.

If your capsular contracture was a result from a cosmetic breast augmentation, they probably will not.  If your capsular contracture was secondary to a breast reduction following a mastectomy - your insurance company probably will.  Best to see your Board Certified Plastic Surgeon and get his/her opinion.  They also might write a letter, on your behalf, to your insurance company seeking prior approval.  The worse that could happen is that your insurance company denies payment.   Good luck. 

Contact your insurance company to discuss your benefits.  Consult with a board certified plastic surgeon for an evaluation.