Insurance and Breast Cancer

Does insurance cover breast reconstruction?

Breast reconstruction procedures are covered by your health insurance plan, whether they are done right away, soon after a mastectomy/lumpectomy, or many years later. This includes procedures that may be needed over time to refine the reconstructed breast and/or to create symmetry (balance) between the two breasts.

The Women’s Health and Cancer Rights Act (WHCRA) of 1998 requires all group health plans that pay for mastectomy to also cover prostheses and reconstructive procedures, including living tissue reconstruction with flaps. In addition, Medicare covers breast reconstruction, while Medicaid coverage can vary from state to state.

The WHCRA:

  • Applies to group health plans for plan years starting on or after October 1, 1998
  • Applies to group health plans, health insurance companies, and HMOs, as long as the plan covers medical and surgical costs for mastectomy

Under the WHCRA, mastectomy benefits must cover:

  • Reconstruction of the breast that was removed by mastectomy
  • Surgery and reconstruction of the other breast to make the breasts look symmetrical or balanced after mastectomy
  • Any external breast prostheses that are needed before or during the reconstruction
  • Any physical complications at all stages of mastectomy, including lymphedema fluid build-up in the arm and chest on the side of the surgery

Our office will communicate with your health insurance provider up front and check on what exactly is covered so you know the actual out-of-pocket cost of surgery. There is an experienced team of administrators in our plastic surgery practice who handle insurance claims. Two of our team members are breast cancer survivors themselves, and have a special perspective on the process. We use specific language and codes to indicate medical necessity, and work to obtain prior authorization before surgery.

As Dr. Fisher specializes in advanced breast reconstruction techniques, we are usually able to obtain an insurance coverage exception for patients who are with an out-of-network insurance plan, called a “gap exception.”

Remember that you’ll still be responsible for your deductible and co-pays. If you’re responsible for a portion of the treatment cost, this might influence your decisions about what type of reconstruction to have. Costs can vary widely, but implant procedures generally do cost less than tissue flaps. However, they’re more likely to require adjustment in the future, so the overall cost may even out.

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