Is Breast Capsulectomy Covered Under Insurance?

, Is Breast Capsulectomy Covered Under Insurance?Breast augmentation is usually considered an elective cosmetic surgery procedure by the insurance companies, and may not be covered under health plans. However, health complications arising from breast implants, such as capsular contracture related issues, often come under the medical, rather than cosmetic category. The patient should contact the insurance provider for coverage details related to breast capsulectomy under her specific insurance policy. Board certified plastic surgeon Dr. Hisham Seify provides breast implants and various other procedures to patients in Newport Beach, Orange County, CA, and surrounding locations.  

Insurance Eligibility

Patients should understand that for breast implant plastic surgery complication to be covered by insurance, it should not simply be an aesthetic issue, such as asymmetry, implant rippling, or unsatisfactory implant size or shape. The breast implant complication must pose a direct risk to the patient’s health if left untreated. Only when such condition is met, the breast capsulectomy procedure may be eligible for coverage by insurance. If the capsular contracture is severe in nature, it will fall under the category of a major breast implant complication with negative health complications if left unaddressed. For this reason, it may be possible to receive insurance coverage for breast capsulectomy surgery. Dr. Seify is a leading cosmetic surgeon providing breast capsulectomy and other procedures to patients in Newport Beach, Orange County, CA, and nearby areas.  

Proper Documentation

While there is no guarantee when it comes to the issue of obtaining insurance coverage for breast capsulectomy surgery, it is possible to increase the chances of coverage with proper documentation. It is worthwhile to spend the time and effort to organize proper documents that detail the precise nature of the problem right from the time when the first symptoms were experienced. The patient must collaborate with the plastic surgeon’s office in order to arrange for accurate and appropriate medical documentation that describes the problem and explains its potential hazards for the patient’s health if the condition is left untreated.  

Degree of Capsular Contracture

For the purpose of obtaining insurance coverage, it is important to define the degree of capsular contracture in the documents. Baker Scale is one of the primary methodologies that insurance providers use to determine eligibility for breast capsulectomy coverage. If the capsular contracture falls within Grade 1 or Grade 2, the insurance company will generally not consider it severe enough to warrant insurance coverage. However, if the capsular contracture is of Grade 3 or Grade 4, it may cause pain, visible deformity, and potentially hinder clear mammography results. In such cases, the insurance providers will often cover breast capsulectomy surgery to resolve these concerns.  

Payment for Specific Procedures

Even when the insurance provider agrees to offer coverage for breast capsulectomy, they may only pay for the part of the surgery that involves implant removal and the scar tissue removal. They will usually not pay for the replacement of breast implants with new ones, or for the replacement of the original implants because this will not directly impact or improve the patient’s health. Though it may improve their psyche, self-confidence, and perhaps even then – income!   See more procedures and treatments by plastic surgeon Dr. Hisham Seify in Newport Beach | Orange County

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