Letter for Capsular Contracture

Here is our sample letter of medical necessity written for a woman with hard or painful breasts caused by capsular contracture (classified as Baker III or IV). If you would like our assistance in personalizing your letter, please take our short survey and we will email you soon.  Click Here to download this letter as a word document you can edit.


[Insurance company] Claims Department
Address Line 1
Address Line 2

RE: Letter of Medical Necessity for [patient name]
Group/policy number: [Number]
Date(s) of service: [Dates]
Diagnosis: [Code & Description]

Dear [Insurance company] Claims Department:

I am writing on behalf of my patient, [patient name], to document medical necessity for explantation of two breast implants. I have diagnosed [patient name] with [Baker III/IV] capsular contracture and severe breast pain. [Patient name] requires an explantation with permanent removal of both implants. On behalf of the patient, I am requesting coverage for this procedure.

[Patient name] is a [age]-year-old female with [Baker III/IV] capsular contracture and severe breast pain. [Patient name] has been in my care since [date]. As a result of her pain, my patient has experienced significant deficits in her daily functioning, including [not being able to reach above her head, etc.]. I diagnosed her with chronic pain resulting from her breast implants. She has previously tried [any pain medications, including Tylenol] to relieve her pain. The attached medical records document [patient name]’s clinical condition and medical necessity for permanent explantation of both breast implants. There is no equally effective course of treatment available for the recipient that is more conservative or less costly.

In addition to my patient’s chronic pain on a daily basis, undergoing mammography has become too painful and the results are too inaccurate. Breast implants can interfere with the accuracy of mammography because the implant can hide breast tumors so that they are not visible on the mammogram. Inaccuracy is exacerbated when the patient has severe capsular contracture, as [Patient name] does. The lack of accurate mammograms makes it difficult to diagnose breast cancer at an early stage when it can be treated more effectively and with less radical treatments. Removal of her breast implants will allow her future mammography screenings to be less painful and much more accurate.

According to the medical policy of [insurance company], my patient’s breast implant removal should be covered since she has severe capsular contracture and breast pain. Her significant breast pain prevents her from [lifting her arms above her head, getting dressed, add relevant tasks]. Surgical implant removal is the standard treatment for chronic breast pain and capsular contracture and clinically appropriate for my patient’s illness. This surgery is not primarily for the convenience of the patient or provider.

The [insurance company] policy [policy number] states the following within the plan under the “[TITLE OF SECTION OF RELEVANT POLICY LANGUAGE]” section:


[Patient name]’s [Baker III/IV] capsular contracture and breast pain meets the above-stated criteria for [breast implant removal/medical necessity]. Removal of both her breast implants and scar tissue surrounding is the standard treatment to relieve her severe breast pain, eliminate her capsular contracture, and improve her bodily functioning. Based on the language above, this procedure should be considered medically necessary.

My patient is requesting coverage for the [surgery name and CPT code #s]. Medical documentation is included.

Based on this information, I ask that you offer coverage for [Patient name]’s medically necessary explant surgery. Should you require additional information, please feel free to contact me at [phone and email contact information]. I look forward to hearing from you.


[Dr. signature]
[Dr. name, title]
[Provider identification number]

Enclosures: (Attach as appropriate)
Clinic notes and lab reports