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 have reconstructive surgery after a lumpectomy?
A cosmetic surgeon with breast reconstruction experience can collaborate with you to build a plan that covers all of your concerns and aspirations. On the Minor Corrections After Reconstruction page, you may learn about some of your alternatives.
In some circumstances, surgery to rebalance the breasts may be necessary. Most plastic surgeons advise waiting 6 to 12 months following a lumpectomy before undergoing any surgical repair. This allows your tissues to recover and any asymmetry or distortion to be corrected. Visit our section on Changing the Opposite Breast for additional details.
Does insurance pay for breast reconstruction revision?
Corrective breast reconstruction surgery is generally covered by health insurance. You may need to deal with your plastic surgeon’s office or your insurance company directly to emphasize that the surgery is medically required, not simply aesthetic, and to obtain permission.
Ask if the plastic surgeon you’re contemplating accepts health insurance up front; others don’t. Some surgeons who accept insurance may demand their patients to perform more of the paperwork or phone calls necessary to get the insurance to cover the treatment. It’s best to inquire about what to expect early on.
You might consider visiting a plastic surgeon who specializes in a form of corrective surgery that isn’t available in your area or selecting a surgeon who isn’t in your health insurance plan’s network. Find out which expenses your plan will cover if this is the case. Travel expenses are often not covered by health insurance coverage. Inquire with your plastic surgeon if you’ll require more than one surgery to achieve the greatest results. You may find that you’ll need to travel for procedures many times, and you’ll want to budget for any out-of-pocket travel costs. See our article on Paying for Reconstruction Procedures for more information on cost management.
Does insurance cover reconstructive surgery after cancer?
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 include 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 religious and government plans, on the other hand, may not be obligated 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 advantages. 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.)
Can you have breast reconstruction after lumpectomy radiation?
Breast reconstruction can be done at a variety of times, depending on your circumstances:
At the same time as the mastectomy. This is what is referred to as “instant reconstruction.” Following the breast cancer surgeon’s removal of the breast, the plastic surgeon reconstructs the breast using tissue from another part of your body or an implant (and sometimes both). Almost all of the work is completed in one operation, and you wake up with a breast that has been rebuilt (or breasts). This strategy necessitates collaboration between the breast cancer and plastic surgery teams. If you need additional treatments like chemotherapy or radiation therapy, immediate repair may not be possible. In some circumstances, a surgeon may advise delaying reconstruction until after these treatments are completed. Alternatively, depending on your circumstances, a surgeon may advise completing part of the reconstruction right away and then finishing it after chemotherapy and/or radiation therapy. You and your surgeon can talk about your specific circumstances and requirements. When you get a preventive mastectomy a mastectomy to lower your risk of breast cancer reconstruction is always performed right away.
Following a mastectomy or lumpectomy, as well as following radiation therapy, chemotherapy, or targeted therapies. This is referred to as postponed reconstruction. Following surgery, treatments like radiation therapy and, in certain cases, chemotherapy can cause the reconstructed breast to lose volume and change color, texture, and appearance. Radiation therapy, in particular, has been documented to alter implant reconstructions in unfavorable ways. Radiation therapy is more likely to be required following surgery for cancers that are larger than 5 cm and have spread to the lymph nodes. Research also suggests that a rebuilt breast may prevent radiation therapy from reaching the cancerous area, albeit this varies from case to case. Some surgeons advise patients to postpone reconstruction until after the radiation and chemotherapy treatments are completed. This indicates that following a mastectomy or lumpectomy, reconstruction may be done 6 to 12 months later.
If desired, reconstruction can potentially be done years afterwards. Some women aren’t ready for surgery right away, or they change their minds about whether they want to “go flat” or use a prosthesis.
As part of a phased approach, some reconstructive surgery is performed during a mastectomy or lumpectomy, and more reconstructive surgery is performed following any additional therapies. This type of reconstruction is also known as delayed-immediate reconstruction. The University of Texas M.D. Anderson Cancer Center was the first to use the newly tiered strategy. After the breast is removed, a tissue expander or standard breast implant is put under the chest muscle and preserved breast skin in delayed-immediate reconstruction. Using a temporary expander or implant to preserve the shape of the breast and breast skin during the impending radiation treatments will allow for the final advantage of a skin-sparing mastectomy method. Tissue expanders are balloon-like devices that stretch the skin to create a “pocket” under the skin for the reconstructed breast. After the radiation is finished and the tissues have healed (usually 4-6 months), the expander/implant that was used to keep the shape of the breast is removed and replaced with a flap from the appropriate donor site, as determined by your surgeon.
Doctors sometimes don’t know if radiation and chemotherapy will help a woman until the cancer and certain lymph nodes have been removed and evaluated. This analysis can take up to a week to complete. If radiation is required, the tissue expander or implant must be left in place until the radiation is finished. The expander is equipped with a port (a metal or plastic plug, valve, or coil) that allows the surgeon to gradually add or remove liquid (a salt water solution). During radiation therapy, some doctors prefer to deflate the expander to allow the radiation oncologist to accurately target the cancer-affected breast region. The tissue expander is progressively reinflated to its original size about 2 weeks after radiotherapy is completed in this example. After more liquid is added to the expander, you may experience some pain or pressure for a few hours. By the next day, this is usually gone. Approximately 4 to 6 months following radiotherapy, the breast reconstruction is usually done.
One of the most hotly debated areas in reconstruction research is the timing of breast reconstruction. Your complete team of doctors, including your breast surgeon, plastic surgeon, radiation oncologist, medical oncologist, and other caregivers, should meet as a group to discuss your specific condition. This group should meet before you decide whether to have a mastectomy or a lumpectomy, because the type of breast surgery you have can affect the success of your reconstruction. Some women, for example, may choose mastectomy over lumpectomy because their plastic surgeon recommends reconstruction following mastectomy for better cosmetic results. Because each breast cancer is distinct, each reconstruction operation and its time are unique. You and your team can decide on the best method for you together.
Women with stage I or stage II breast cancers who select mastectomy based on a biopsy are less likely to require radiation or other therapies following mastectomy and are often suitable candidates for rapid reconstruction. Because it combines the mastectomy and reconstruction into one surgical surgery, this is their greatest option. The tiered technique may be employed instead if there is a good possibility that radiation will be required. Your surgeon will help you determine the timing that is right for you.
Because of the size of the disease or the number of lymph nodes involved, women diagnosed with stage III or stage IV cancer nearly usually require radiation therapy or other treatments after mastectomy. Some doctors advise deferring reconstruction until all other breast cancer therapies have been done in this scenario. Reconstruction may necessitate additional healing time, which could cause radiation and chemotherapy to be delayed.
However, in some circumstances, quick reconstruction may be necessary. If you undergo chemotherapy as your first treatment for breast cancer, for example, your tumor may be able to be downstaged. After that, you might be a candidate for a skin-sparing mastectomy, which keeps as much of the breast skin as possible. While radiation may still be required, your doctor may be comfortable with its potential consequences on a flap restoration done right away. Alternatively, your doctor may recommend a phased reconstruction with a tissue expander or saline implant to keep a breast pocket during your therapies. You and your doctor can talk about which option is best for you.
If you’re not sure whether stage of breast cancer applies to you, consult your doctor. You might also want to look at the Breast Cancer Stages page.
The resources and expertise available in your area are as follows: If you want immediate reconstruction with your own tissue (autologous reconstruction) or an implant, you’ll need two surgeons with credentials and operating privileges in the same hospital who can collaborate: a breast cancer surgeon who will perform the mastectomy and a plastic surgeon who is experienced in the type of reconstruction you want. Some of the latest flap reconstruction techniques necessitate microsurgery expertise, which entails connecting the tissue flap’s tiny blood veins to vessels in the chest area so the flap can receive the blood supply it requires in its new “home.” This is a skill set that not all plastic surgeons possess. Microsurgery frequently necessitates the involvement of two plastic surgeons in addition to the breast surgeon.
Also, because the delayed-immediate approach is new and involves a little more work than either instant or delayed reconstruction timing, it isn’t available everywhere now. Surgeons having experience with this method are more likely to be found in large city cancer centers and cancer centers linked with universities. If you have strong feelings about a certain scheduling strategy, you may need to speak up for yourself and consult with many breast surgeons. Discuss the best scheduling possibilities for your specific circumstance with your oncologist, as well as the surgeons in your area.
Your decision-making style is as follows: Receiving a breast cancer diagnosis can be terrifying and stressful. Making decisions about mastectomy or lumpectomy, as well as other treatments, can be draining emotionally. Making even more decisions regarding what type of reconstruction to have and when to get it may be too much for you to handle. However, keep in mind that, despite appearances, mastectomy is not usually an emergency procedure. You have time to consider and halt. Take some time to clear your mind, conduct your own study, and weigh the pros and cons of other viewpoints. Instead of reacting to current situations, try to make a decision that is long-term oriented. Ask your doctor about the differences between immediate and delayed reconstruction in terms of near-term healing and long-term outcomes if you opt not to have reconstruction right away.
Your general wellbeing: If you have diabetes, cardiovascular issues, or a bleeding disorder, your doctor may advise you to wait until you have fully recovered from your mastectomy before undergoing reconstruction. You may, nevertheless, be qualified for urgent reconstruction; however, this decision must be decided on a case-by-case basis. Heavy smoking might impair your ability to heal, so your doctor may advise you to stop smoking for a period of time prior to reconstruction surgery so that your body can heal more quickly.
Is a lumpectomy considered major surgery?
A lumpectomy is a surgical treatment that removes a mass from the breasts, either malignant or non-cancerous. Only the afflicted area of the breast is removed during a lumpectomy, leaving the healthy breast tissue alone. Breast-conserving surgery is sometimes known as a lumpectomy. Lumpectomy is a regular procedure, yet it is still a serious procedure with risks and repercussions. Following a lumpectomy, other therapies like as chemotherapy and radiation therapy may be required. A lumpectomy may be sufficient for non-cancerous (benign) tumors.
The most prevalent type of benign, non-cancerous breast tumor is fibroadenoma. It mainly affects young, premenopausal women between the ages of 15 and 40. It can also happen if you’re pregnant or breastfeeding. They rarely cause issues and are easily cured with surgery.
Breast cancer develops in breast cells and can spread to other parts of the body (metastasis). Breast cancer can strike men on occasion, however it is extremely rare. A lumpectomy can be performed if the tumor is tiny, has no local invasion, and is localized to one breast. Other surgical treatments may be required if this is not the case.
What to expect after lumpectomy
Women who want to maintain their breast and have it look (as much as feasible) like it did before surgery may opt for a lumpectomy rather than a mastectomy.
Lumpectomy, on the other hand, will alter the appearance and feel of the breast. The breast may be smaller as a result of the tissue removal. There will be a scar and numbness as well. Inquire with your doctor about products that may aid in the reduction of the scar’s appearance.
The appearance of the breast can also be affected by radiation therapy (which is commonly administered after a lumpectomy). It can cause the breast to shrink even more and affect its texture or make it seem firmer.
During the first 1-2 years after surgery and radiation therapy, the appearance and feel of your breast will change.
When mastectomy may be a better option
The position and size of the tumor can make it difficult for a woman to be satisfied with the appearance of her breast following a lumpectomy. Mastectomy (with or without breast reconstruction) may be the preferred option in these instances.
Breast reconstruction after lumpectomy
Breast reconstruction (either at the time of the lumpectomy or subsequently) may be necessary in rare circumstances to retain a more natural appearance of the breast or to match the size and form of the other breast.
Because these procedures are complicated, it’s advisable to consult with a plastic surgeon about your alternatives.
How many surgeries are required for breast reconstruction?
A. Breast reconstruction normally entails more than one surgery because it takes two or more surgeries to finish the process while providing time for healing in between. A revision procedure is sometimes used as part of the process. Other treatments, such as reconstructing the areola or applying a nipple tattoo, may be required as a follow-up surgery to establish symmetry. “Everyone is different in terms of what she needs and desires,” Dr. Liu adds, adding that this is something every patient should discuss with her surgeon.
Is a preventive mastectomy covered by insurance?
Women may opt for a preventive mastectomy to alleviate their fears of developing breast cancer. It may also make them feel as if they’ve done everything they can to reduce their breast cancer risk.
Pros and cons of bilateral prophylactic mastectomy
If you’re at a high risk for breast cancer, talk to your doctor about the benefits and drawbacks of a preventative mastectomy. You should also speak with a plastic surgeon about your breast restoration alternatives.
Younger women appear to benefit more from preventive mastectomy than older ones. This is due to the fact that younger women have more years ahead of them.
- Prophylactic mastectomy may add 3-5 years to the life of a 30-year-old woman with a BRCA1 or BRCA2 hereditary gene mutation.
- After a preventative mastectomy, the increase in lifespan for women 60 and older is minimal.
Aside from the emotional burden of losing both breasts, some women struggle with body image concerns, which can affect how they feel sexually following a preventive mastectomy. These difficulties can be addressed by speaking with a health care practitioner or counselor, or by joining a support group.
Breast reconstruction
You may want to get breast reconstruction if you had a preventive mastectomy. This might be done concurrently with the mastectomy or at a later date.
Insurance coverage
Prophylactic mastectomy is required by some state legislation, however coverage varies by state.
It’s wise to call your insurance carrier to find out what your plan covers.
Is breast asymmetry surgery covered by insurance?
- Several breast surgeries performed at The Sayah Institute may be eligible for insurance reimbursement or payment:
- Asymmetrical Breasts: Although all women have some degree of asymmetry between their breasts, excessive examples may necessitate surgery. Insurance may reimburse an aesthetic breast treatment performed to correct a considerable degree of asymmetry.
- Although not all breast lumps are cancerous, they may nonetheless necessitate a full or partial mastectomy or lumpectomy, as well as reconstructive breast surgery.
- Women who test positive for the BRCA1 or BRCA2 gene may choose for a prophylactic mastectomy to reduce their risk of getting breast cancer. A preventative mastectomy should leave more optimal scars when performed by a board certified plastic surgeon.
- Breast Implant Complications: Insurance generally covers revision surgery for implants that have changed in location, ruptured or leaked, or other complications associated to breast implants.
- Insurance companies that cover the costs of a primary operation are also required to cover the costs of reconstructive breast surgery after a mastectomy or lumpectomy. This could entail implant restoration, flap reconstruction, or other procedures to restore breast symmetry.
- Breast Reduction: Because macromastia, or the condition of having very large breasts, can result in a multitude of secondary health issues such as back and neck pain, breast reduction is largely a medical treatment rather than an aesthetic technique.
- Capsular Contracture: Scar tissue growth around breast implants is a typical component of the body’s healing process. An expansion of scar tissue, on the other hand, might feel rigid or even painful, and it can also cause implant displacement. The scar tissue capsule is loosened or eliminated during breast revision surgery for a beautiful, natural look.
- Congenital Abnormalities: Congenital deformities can be mitigated or rectified by reconstructive breast surgery, whether they are present from birth or only become obvious during puberty.
- Gynecomastia is the growth of male breasts caused by a hormonal imbalance, which usually occurs during puberty.
- Male breast reduction removes extra glandular and fatty breast tissue to display greater muscle definition and corrects the look of gynecomastia.
- Inverted Nipples: Nipples may be inverted from birth or develop over time as a result of breastfeeding issues, ptosis (droopy breasts), or physical trauma to the breast. Both men and women can have their nipples retracted through surgery, which is usually done as an outpatient operation.
- Tubular Breasts: Tissue constriction during breast development in adolescence can cause breasts to seem tuberous. This tightness can be loosened and adjusted for a rounder, softer shape, either with or without implants, with the right surgical method.
Do you have any other concerns about your insurance coverage? The Sayah Institute can be reached at
Is breast reconstruction medically necessary?
It had been four years since Marianne Sarcich first felt the lump in her right breast as she toweled off following a shower on a hot July night.
Although the cancer was discovered early enough that it had not spread to other regions of her body, doctors advised that she undergo a mastectomy to remove the breast and the malignancy within it.
After the procedure, the implant she received developed scar tissue, became painful, and had to be removed.
Sarcich chose a fresh type of surgery this time, in 2020, in which tissue from her left thigh was transplanted to her chest to make a breast.
“I couldn’t look at my chest for months after the mastectomy, so I avoided mirrors.” Sarcich, 55, of Wilmington, said, “It took me so long to realize this was me.”
Her relief was fleeting. Her health insurance covered the repair surgery, but she quickly discovered that a follow-up procedure to slim her right thigh to match the left was not.
Health insurance must cover breast reconstruction after a mastectomy, as well as any follow-up surgeries to restore symmetry between the breasts, according to federal and state legislation. However, when tissue is extracted for reconstruction, patients frequently struggle to obtain insurance reimbursement for surgery to restore the appearance of other portions of their body.
The process of appealing insurance denials can be intimidating, especially for people who have been through cancer treatment and recovery and are physically and emotionally tired. Those who are unable to navigate the denials process may be denied follow-up care.
“A woman should not have to fight her insurance provider at a time when she is literally fighting for her life in obtaining breast cancer treatments and a very disfiguring operation,” said Pat Halpin-Murphy, president of the Pennsylvania Breast Cancer Coalition. “She’ll need all of her might to heal.”