Are you experiencing breast capsulectomy side-effects where the capsule surrounding your breast implant is hard and produces chronic pain? Is your body processing too much collagen, hardening the capsule at one or both implants after your breast augmentation procedure? Are you questioning if your health insurance provider will possibly cover removing your implants?

Not all insurance policies are the same as it relates to plastic surgery procedures. The quick answer depends on your plan and how it’s tailored to your health needs. Breast augmentation and explant surgery, like most invasive cosmetic surgeries, are considered optional. Talking with your health insurance provider and knowing which benefits are covered will let you know if you can get all or most of the cost met. No one like to read the fine print, but it’s imperative to review the benefits section of your policy. You possibly can qualify for some insurance coverage for your breast surgery.

As stated by the National Center for Health Research, insurance companies do care about breast augmentation surgeries and why you got them in the first place.

Is it Likely a Capsulectomy Procedure is Covered?

  1. Asking yourself why you opted for breast implants in the first place is an excellent place to start. If it was for vanity, then it’s probably not going to be covered.
  2. Were your breast implants placed after a mastectomy, and your doctor deems removal as medically necessary? If so, under the Women’s Health and Cancer Rights Act of 1998 (WHCRA), your health insurance provider is obligated to cover an explant surgery. It’s the law.
  3. Is your breast disfigured from an implant failure (tear or rupture), capsulectomy, or a critical capsular contracture? Then maybe.
  4. Health insurance companies will only cover removing breast implants, known as explant surgery.
  5. Numerous health insurance policies have exemptions for specific incidents that consider reconstructive or medically necessary surgery due to breast implant complications.

What is Undoubtedly Not Covered by Health Insurance

  • Your breasts were considered healthy at the time of your augmentation, and now you want to remove them.
  • Fat transfer to the chest, breast lift, breast reconstruction, or replacing breast implants because of loose or sagging skin.
  • You have second thoughts about your breast augmentation, and now you’re stressed out.
  • Autoimmune diseases and symptoms.
  • You’re experiencing side effects that aren’t life-threatening.
  • You and your doctor see your situation as medically necessary. It doesn’t mean your health insurance provider will be on the same page and see your condition the same.

What is a Medically Necessary Condition?

As mentioned above, health insurance policies vary from person to person and state to state. Calling your provider and speaking to your representative to thoroughly go over your benefits will remove any confusion about what is covered and considered medically necessary.

How Do I Know If My Capsular Contracture Will Require Surgery?

Below is a list of FAQs regarding capsular contracture. It’s rated on a four-grade scale known as the Baker’s Classification:

  1. BAKER GRADE I: the breast is naturally soft and appears consistent in size and shape
  2. BAKER GRADE II: the breast is slightly stiff yet looks healthy
  3. BAKER GRADE III: the breast is hard and looks unnatural
  4. BAKER GRADE IV: the breast is dense, has severe pain with touch, and appears irregular

Grade I and Grade II capsular contracture generally do not require surgery. If you are experiencing Grade III and Grade IV capsular contracture, most likely surgery or a minimally invasive procedure to achieve natural-looking breasts is needed. If you smoke, stop. It will greatly support blood flow and the body as you heal. Additionally, discontinuing certain medications is necessary.

What Is Capsulectomy Reconstructive Surgery?

When surgery is medically necessary, health insurance companies acknowledge a reconstructive explant surgical procedure to treat a medical condition. Surgery entails an incision along the original scar from your augmentation, removing the envelope surrounding the implant where it will be removed or reinserted. Once the incision is closed, the breasts are protected with a bandage. If there are no complications, you can go home in less than 24 hours after and a short rest in recovery. The overall healing stage is approximately two weeks.

 Next Steps After Talking with My Health Insurance Company?

Talking to your health insurance company representative to fully understand if they can or will cover breast removal surgery costs is the right first step. Next, finding a board-certified plastic surgeon with extensive knowledge of capsulectomy surgery is the second step.

Now that you know more about the condition, financial, and insurance responsibilities, contact Barrett Plastic Surgery at 310-598-2648 to schedule a consultation. If you’re more at ease speaking with our team from the convenience of your home, we provide virtual surgical consultations. Do you want to learn more about Barrett Plastic Surgery? Stay current by subscribing to our blog and following us on social media at Twitter, TikTok, Instagram, Realself, YouTube, Snapchat, Yelp, and Facebook for updates.

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