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.
