Breast revision surgery is a treatment or set of operations used to improve or repair a previous breast surgery’s unsatisfactory outcome. This could be due to age-related changes in the body altering surgery outcomes, your body responding in an unanticipated way throughout the healing period, or simply a desire for a new look.
Breast revision surgery can treat a variety of difficulties from a previous procedure, such as implant placement issues or unequal breasts (asymmetry), scar improvement, reducing excess scar tissue surrounding the implants (capsular contracture), and implant replacement, removal, or modification. Regardless of why you needed revision surgery in the first place, the goal of breast revision surgery is to offer you beautiful, natural-looking outcomes.
Patients who are considering breast revision surgery are concerned about whether their insurance would cover the treatment. Breast revision surgery is frequently covered by health insurance companies, especially if it is linked to:
How much does it cost to even out your breasts?
The average cost of a breast lift in 2019 was $4,693, according to the American Society of Plastic Surgeons (ASPS). In the same year, the ASPS estimated the average cost of breast augmentation to be $3,947. The total cost of the procedures was estimated to be around $6,225 on average.
Keep in mind that these figures only represent a portion of the entire cost; they exclude anesthesia, facility fees, and other costs.
The cost of your operation will vary greatly based on where you live and whether or not your insurance covers any of it.
What type of breast surgery is covered by insurance?
Breast augmentation surgery, which involves the placement of breast implants for cosmetic reasons, will cost an average of $4,516 in the United States in 2020.
The majority of women are responsible for paying this out of their own pockets. Breast augmentation surgery is frequently not covered by insurance. Breast implants will, however, be covered for women who have had mastectomies owing to breast cancer.
If you require additional surgery in the future, your health insurance may not pay it. Breast implants may effect your insurance rates in the future.
Is corrective breast surgery covered by insurance?
Breast reconstruction operations should be covered by your health insurance plan whether they are performed immediately after a mastectomy/lumpectomy or several years afterwards. Procedures to improve the reconstructed breast and/or produce symmetry (balance) between the two breasts may be required over time.
All group health plans that pay for mastectomy must also cover prosthesis and reconstructive operations, according to the Women’s Health and Cancer Rights Act of 1998. Furthermore, Medicare covers breast reconstruction, although Medicaid coverage varies by state. You should check with your plan administrator because government and church-sponsored plans are not always obligated to cover rehabilitation.
Even if you’re insured, complications can arise, particularly in certain situations: for example, if you’ve chosen a newer form of reconstructive treatment, if you’re undergoing surgery to create a more balanced appearance, or if you require a thorough repair of a previous reconstruction. If you want to see a plastic surgeon who isn’t in your health insurance plan’s network, coverage can be a problem.
It’s usually advisable to check with your health insurance carrier ahead of time to see what’s covered so you don’t have to deal with the hassle of attempting to collect payment later. You can also work with the insurance claims administrator at your plastic surgeon’s office. Your state’s health insurance agency and commissioner are another potential resource, as several jurisdictions have implemented new legislation requiring coverage for breast reconstruction.
Here are some questions to ask your insurance company and the cosmetic surgeon’s office to help you get started:
- Is a mastectomy covered by my insurance? (It must cover reconstruction if the answer is yes.)
- What expenses will be covered if I travel to another surgeon who specializes in a method that isn’t available in my network?
The Breast Reconstruction Guidebook, by Kathy Steligo (Baltimore: The Johns Hopkins University Press, 2017), pp. 207-208.
Remember that your deductible and co-pays will still be your responsibility, so be sure you know how much you’ll be spending out of pocket. If you’re accountable for a portion of the treatment costs, it may impact your choice of reconstruction. Although prices vary, implant operations are generally less expensive than tissue flaps. They are, however, more likely to require change in the future, so the total cost may be equal.
According to Frank J. DellaCroce, M.D., FACS, plastic surgeon and co-founder of the Center for Restorative Breast Surgery, how your plastic surgeon’s office interacts with your insurance company regarding your surgery can make a big difference. The office must utilize wording that makes it obvious that the procedure is medically required rather than merely aesthetic. “If you’re repairing a rebuilt breast that has gotten deformed, for example, or balancing the two breasts, the insurance plan may deny reimbursement right away, claiming, “Well, that’s cosmetic.” Instead, we might have to state, “After mastectomy, she had asymmetry in the breast that caused a cup size discrepancy that made apparel and function problematic, and she has an overall imbalance that is developing a symmetry deformity.” When you set things out like way, it’s tougher for them to respond, “Well, too bad.” It starts to feel more real.”
- Make sure the office is utilizing the ICD-9 (soon to be ICD-10) code, which is the standard classification system that all insurance companies follow.
- Don’t give up. If your claim is refused, you and your doctor can amend the description and send a non-identifying photo (of your chest just, not your face) to show the issue area (s).
- As you move on with your case, keep comprehensive paper records of all communications.
“We normally have success,” Dr. DellaCroce says, “but the way the physician’s office conveys the issue to the insurer will either ensure coverage or guarantee denial.”
Our blog, Reconstruction Coverage Under the Women’s Health and Cancer Rights Act, is also worth reading.
Can you fix asymmetrical breasts?
Breast augmentation is a simple way to fix asymmetry in the breasts. Your surgeon may propose breast implants in one or both breasts, depending on the severity of your asymmetry and your desired results.
Every surgery is tailored to the individual needs of each patient by our surgeons. They may propose breast augmentation in the smaller breast and breast reduction in the larger one if your asymmetry is significant. A breast lift may be performed in conjunction with your breast augmentation treatment to provide optimal results if your asymmetry is related to shrinking. Different-sized implants may be the most effective technique to treat breast asymmetry in some circumstances.
During your initial consultation, your surgeon will go over all of these options with you in great detail and work with you to find the best way to reach your specific objectives. He’ll also go through the various breast implant alternatives you have, since both saline and silicone implants can produce excellent outcomes when it comes to addressing breast asymmetry.
Will my insurance cover breast reconstruction?
Is it legal for insurers to drop people from their plans so they don’t have to pay for breast reconstruction?
No, the WHCRA prohibits insurance plans and corporations from kicking people out of plans or preventing them from enrolling in or renewing their coverage to evade WHCRA requirements.
Is it legal under the WHCRA for insurance companies to pay doctors to discourage women from seeking breast reconstruction after a mastectomy?
No. The WHCRA prohibits insurance plans and issuers from penalizing doctors or pressuring them to deliver care that is incompatible with the WHCRA. It also prohibits insurance companies from rewarding doctors who do not advise their patients to consider breast reconstruction.
Is it necessary for my insurance company to inform me that I am insured for breast reconstruction under the WHRCA?
Yes. The law also requires insurance companies to advise you of this coverage when you first enroll in their plan and then every year thereafter.
Several states have passed legislation requiring health insurers that cover mastectomies to cover reconstructive surgery following the procedure. These state laws only apply to health plans purchased from a commercial insurance carrier by an employer. State laws do not apply to self-insured employers, but federal laws do.
A self-insured (or self-funded) plan is one in which the employer pays for the insured person’s medical bills rather than a commercial insurance provider. Even while the money for the payments still comes from the employer, some self-insured firms will hire a commercial insurance company to make the checks and handle the paperwork. So unless you inquire, it’s difficult to tell if you’re in a self-insured or commercially insured plan.
I’ve been told I have breast cancer and will need a mastectomy. What impact will the WHCRA have on my benefits?
Group health plans, insurance companies, and HMOs that provide mastectomy coverage must also cover reconstructive surgery after the mastectomy, according to the WHCRA. This coverage includes mastectomy reconstruction, reconstruction of the other breast to create a more balanced appearance, breast prosthesis, and treatment of physical problems, such as lymphedema, at all stages of the mastectomy.
This federal statute establishes a minimum standard to ensure that women who have had a mastectomy can get breast reconstruction, even if they live in states where insurance companies are not required to pay it.
Is it true that the WHCRA mandates that all group plans, insurance companies, and HMOs cover reconstructive surgery?
Yes, in most situations, as long as the insurance plan also covers mastectomies’ medical and surgical benefits. Certain church and government plans, on the other hand, may not be required to cover reconstructive surgery.
Check with your plan administrator if you are covered by a health plan provided by a church or a municipal government.
Can insurance companies apply deductibles or co-insurance requirements for reconstructive surgery after a mastectomy under the WHCRA?
Yes. However, the deductibles and co-insurance must be the same as those for other plan or coverage benefits. The insurance company cannot require you to pay a larger deductible or co-pay for breast reconstruction than you would for other procedures.
Am I eligible to the state and WHCRA-mandated minimum hospital stay if I get a mastectomy and breast reconstruction?
It is debatable. You would be entitled to the minimum hospital stay needed by state law if you have coverage via your work and your employer is insured. State law does not apply if you receive coverage through your workplace but it is not supplied by an insurance company or HMO (i.e., your employer “self-insures” your coverage). Only the federal WHCRA applies in this case, and it does not impose any minimum hospital stays. Contact your plan administrator to learn whether your group health plan is insured or self-insured.
If you have private health insurance (not through your company), check with the office of the State Insurance Commissioner to see if state law applies.
No. The WHCRA does not prevent a plan or health insurance issuer from haggling with doctors regarding payment amounts and types. However, the law prohibits insurance companies and issuers from penalizing doctors or giving incentives to encourage them to provide care that is in violation of the WHCRA.
No. The Affordable Care Act made no changes to the WHCRA, and there are no rules or regulations that affect it. Breast reconstruction must be included in health insurance policies that provide mastectomy.
Even so, if you underwent a mastectomy due to breast cancer, Medicare will cover breast reconstruction.
Because Medicaid coverage differs by state, you’ll need to find out what’s available in yours.
- For WHCRA information, go to the US Department of Labor’s website or call 1-866-487-2365, which is a toll-free number.
- For information about employer-based health insurance, contact the Department of Labor’s Employee Benefits Security Administration at 1-866-444-3272.
- Your insurance company’s administrator (a number should be listed on your insurance card)
- The office of your state’s insurance commissioner (The number should be in the state government section of your local phone book, or you can look it up on the National Association of Insurance Commissioners’ website or call 1-866-470-NAIC) (1-866-470-6242.)
How do I get my insurance to cover a breast reduction?
Large breasts (macromastia) can produce physical problems that interfere with a woman’s daily functioning, as I discussed in my earlier post. Symptomatic macromastia is a well-known medical disorder that requires treatment. Insurance coverage of reduction mammaplasty is just as suitable as coverage of cervical spine surgery, shoulder surgery, carpal tunnel release, or sleep apnea treatment because big breasts put constant strain on body systems. Non-surgical treatments should be attempted initially for some disorders, but there are no non-operative treatments for macromastia that are expected to provide long-term or permanent symptom alleviation.
If you’re thinking about having breast reduction surgery, make sure you read your insurance coverage first. If your insurer specifies reduction mammaplasty as a policy exclusion, you might not even be able to get coverage for a consultation to see if surgery is right for your symptoms.
In most situations, insurers demand that the surgeon produce a statement outlining the patient’s symptoms and physical results, as well as an estimate of the breast weight to be removed and a request for coverage. This should be done before scheduling surgery since if surgery is not preauthorized, the insurer may refuse to pay. If your insurer refuses to pay breast reduction surgery because it is considered cosmetic, your doctor must inform the insurer about symptomatic macromastia and the differences between breast reduction and its aesthetic cousin, the breast lift. Traditional Medicare and Medicaid plans may not offer preauthorization.
Current insurers should be aware of the current standard of care for treating macromastia and should accept coverage based on reasonable criteria and medical necessity verification. Unfortunately, too many insurance companies have yet to study the medical research from the last two decades demonstrating the usefulness of breast reduction surgery in alleviating macromastia symptoms independent of a woman’s body weight. Many of these businesses employ a chart based on the Schnur Scale of 1991, which correlated a woman’s reasons for breast reduction with her body weight. Because of their position on the chart, many women are denied coverage. The use of such a chart to discriminate against overweight women by refusing them coverage regardless of their symptoms has no medical validity, according to recent medical research, but insurers continue to do so.
Your doctor’s report of your symptoms and physical changes caused by your breast weight should be utilized to determine medical necessity. Even though non-surgical therapy trials have a low chance of success, they may be required before surgery is covered by insurance. Although it is reasonable for an insurer to require that a certain amount of breast tissue be removed, there should be a mechanism in place to ensure that special circumstances (such as a small-framed woman or a woman with a medical condition made worse by even moderate breast weight) are given special consideration.
You have the legal right to appeal a denial if you believe breast reduction is important for your health and well-being. The denial letter should include information about the appeals process. Multiple levels of appeal are available in most circumstances, and you should take use of them. A family doctor’s letter, an orthopedist’s letter, a physical therapist’s letter, a chiropractor’s letter, or a massage therapist’s letter can all help support an appeal. You should create your own letter in which you describe your symptoms and how they have hampered your life (focus on your physical problems rather than your difficulty finding a bathing suit). Request that your doctor attach your personal letter, supporting letters, current scientific information on the standard of treatment for treating symptomatic macromastia, and a list of medical literature references to your appeal.
Are breast deformities covered by insurance?
POLICY Reconstructive surgery, such as breast reconstruction to rectify abnormalities and surgery on the contralateral breast to establish symmetry, is considered reconstructive surgery and should be covered by third-party payers.
Does insurance cover top surgery?
The tide is turning in the United States, with more insurance companies recognising the medical necessity of gender-affirming procedures and funding Top Surgery.
What can go wrong with breast reconstruction?
Your plastic surgeon and/or staff will go through all of the potential hazards involved with your procedure in great detail. You may be required to sign consent paperwork to ensure that you are completely aware of the operations you will be undergoing, as well as any risks or issues that may arise. Your decision to get breast reconstruction has no effect on your chances of recurrence of breast cancer.
Breast reconstruction hazards include, but are not limited to, bleeding, infection, poor incision healing, and anaesthetic concerns. You should also be aware of the following:
- The danger of partial or complete flap loss, as well as loss of sensation at both the donor and reconstruction sites, is associated with flap surgery.
- Breast firmness (capsular contracture) and implant rupture are risks associated with implant use.
- Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a form of immune system cancer that is most commonly associated with textured implants.
- Breast implants may cause systemic symptoms such as weariness, “brain fog,” muscle or joint discomfort, and rash, which are referred to as breast implant sickness (BII).
- Complications or issues may be more likely with acellular dermal matrix products.