Sample Letter of Medical Necessity

Here is a sample letter of medical necessity written for a woman with ruptured silicone gel implants and severe capsular contracture. For help writing your own letter of medical necessity, contact us at info@breastimplantinfo.orgClick here to download.

Breast Implant Removal Office
555 Smiles Way
Healthytown, DC 55555

January 5, 2018

XYZ Claims Department
167 Daisy Lane
Milwaukee, OK 12345

RE: Letter of Medical Necessity for Jane Doe

Group/policy number: 1425-2345-1234
Date(s) of service: January 2, 2018

Dear XYZ Claims Department:

I am writing on behalf of Jane Doe, to document medical necessity and request prior-authorization for explantation of two silicone gel breast implants. Ms. Doe is a 56-year-old female with rupture of her right implant, Baker level III capsular contracture in her left implant, and significant pain in both breasts. She has been in my care since September 21, 2017. Ms. Doe requires an explantation with permanent removal of both implants.

As a result of her pain, Ms. Doe has experienced significant deficits in her daily functioning, including not being able to reach above her head, get dressed, or drive to work. She has previously taken a variety of over-the-counter and prescription pain medications, which have not alleviated her pain. The attached medical records document Ms. Doe’s clinical condition and medical necessity for permanent explantation of both breast implants. There is no equally effective course of treatment available for this patient that is more conservative or less costly.
My patient’s XYZ policy states the following:

“Removal of breast implants that were initially placed for cosmetic purposes is covered when it is considered medically necessary to treat illness or restore the functioning of a body part.”

According to the medical policy of XYZ, Ms. Doe’s breast implant removal should be covered because she has severe capsular contracture that interferes with her daily functioning and has interfered with mammography. Removal of her breast implants and scar tissue surrounding them should relieve her breast pain and eliminate her capsular contracture.

Surgical implant removal is the standard treatment for severe capsular contracture and ruptured silicone-gel breast implants, and this procedure is clinically appropriate for my patient’s condition. Based on the language above, this procedure should be considered medically necessary.

I ask that you take the above information into consideration and offer coverage for Ms. Doe’s medically necessary explant surgery. Should you require additional information, please feel free to contact me at (111) 111-1111 or


Dr. David Healthcare, Chief of Breast Implant Removal Operations
NPI# 1234567890

Ms. Doe’s Office Visit Notes from 9/21/2017
MRI Report from 11/10/2017
Ms. Doe’s post-operative report from 1/2/2018