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.”
Is breast cancer reconstruction 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.
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.)
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 charges 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.
How much does a mastectomy and reconstruction cost?
Mastectomies can cost anywhere from $13,000 to $21,177 without insurance. The American Society of Plastic Surgeons does not publish typical surgeon fees for mastectomy breast reconstruction. The typical cost of reconstruction is estimated to be between $5,000 and $8,000.
Does insurance pay for preventive mastectomy?
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 reconstructive surgery covered by insurance?
Most health insurance companies fund reconstructive surgery because it is considered medically necessary. If the goal is to ease pain and suffering, nasal surgeries, breast reduction, and weight loss are all options. Some insurance companies cover only the medically required portion of a surgery.
Does Medicare cover reconstructive breast surgery?
If you underwent a mastectomy due to breast cancer, Medicare will cover breast prosthesis for reconstruction. Non-covered services, like as most cosmetic surgery, are entirely your responsibility.
Do you need 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.
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