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.
How much does breast reconstruction cost?
In the private sector, the approximate out-of-pocket cost for DIEP flap surgery (as of February 2020) is:
A bilateral treatment (double reconstruction) costs approximately $25000-30000, which includes the cost of two plastic surgeons, surgical helpers, an anaesthetic, and all follow-up. There are no additional expenses if there are any issues.
A unilateral treatment (single reconstruction) costs around $17000-22000, which includes the cost of two plastic surgeons, surgical helpers, an anaesthetic, and all follow-up. There are no additional expenses if there are any issues.
These costs assume adequate health insurance coverage and exclude payments for a breast surgeon (if necessary) and the hospital excess.
How much is breast reconstruction surgery with insurance?
- Breast reconstruction with “flap” techniques (using tissue from the patient’s own body to generate new breasts) can cost anywhere from $25,000 to $50,000 or more without health insurance, or $50,000 to $100,000 for both sides. It’s not uncommon for total costs to range from $100,000 to $150,000.
- Out-of-pocket expenditures for breast reconstruction range from a few hundred to several thousand dollars with health insurance. Costs can range from $10,000 to $12,000 or more in some circumstances. Patients discussing out-of-pocket prices for the most expensive surgeries on a breast cancer forum.
- Breast reconstruction after a mastectomy is covered by health insurance. All U.S. health insurers and self-insured group plans that cover mastectomy must also cover post-mastectomy breast reconstruction, surgery on the other breast to create symmetry, and treatment of post-reconstruction complications, according to the federal Women’s Health and Cancer Rights Act of 1998. Some states have passed legislation requiring insurance coverage.
- Reconstruction can be done right after a mastectomy in some situations; in others, especially if radiation is utilized, reconstruction takes months or even years following the mastectomy.
- With an implant, the surgeon normally stretches the skin by placing a tissue expander under the skin and muscle, then slowly inflates it with saline over a four- to six-month period. The expander is physically removed and replaced with a silicone gel or saline implant after the expansion is complete, usually in an outpatient operation that takes an hour or two under general anesthesia and requires two to four weeks off work for rehabilitation.
- The surgeon removes skin, blood arteries, and, in some older techniques, muscle from the abdomen, back, or buttocks and uses that tissue to re-create the breast via flap methods. These inpatient procedures usually require general anesthesia, take four to twelve hours to complete, and can result in up to a week in the hospital and two months off work. These treatments are difficult and necessitate the services of a professional microsurgery specialist. Some consider the DIEP Flap operation to be the most advanced technique available. The SIEA Flap, TUG Flap, GAP Flap, TRAM Flap, and Latissimus Dorsi Flap are some of the other alternatives. The surgery that is indicated is determined by the amount of tissue in a certain place, previous surgeries, and other health conditions. Months following the initial operation, one or two further outpatient surgeries (a few hours each) are usually required for corrections (smoothing out scars or injecting fat) and nipple and areola development. Patients discuss the various stages of surgery on a breast cancer forum.
- After 10 to 15 years, an implant will need to be replaced; replacement is usually covered by insurance.
- For the initial consultation and at least two to three surgeries, many patients must pay travel and lodging expenditures.
- A permanent makeup artist or plastic surgeon tattoos a nipple and areola normally many months after nipple repair for $200 to $600 per breast; some providers give the service for free to breast cancer survivors.
- My Hope Chest is a non-profit organization that assists ladies in need of breast reconstruction. Furthermore, the United Breast Cancer Foundation provides financial assistance to people in need.
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 cover mastectomy reconstruction?
Many women with breast cancer who choose to have their breasts rebuilt (reconstructed) after a mastectomy benefit under the Women’s Health and Cancer Rights Act (WHCRA). A mastectomy is a procedure that involves the removal of all or part of the breast. Most group insurance plans that provide mastectomies must also cover breast reconstruction under this federal law. On October 21, 1998, it was signed into law. This statute is overseen by the US Departments of Labor and Health and Human Services.
The Affordable Care Act provides extra safeguards (ACA). A group health plan cannot limit or refuse benefits due to a pre-existing condition for plan years beginning on or after January 1, 2014 (a plan year can be any 12-month term that the insurer chooses).
The WHCRA:
- For plan years beginning on or after October 1, 1998, this rule applies to group health plans.
- As long as the plan covers medical and surgical expenditures for mastectomy, it applies to group health plans, health insurance companies, and HMOs.
Under the WHCRA, mastectomy benefits must cover:
- After a mastectomy, surgery and reconstruction of the second breast are performed to make the breasts appear symmetrical or balanced.
- Any external breast prostheses (breast forms that fit into your bra) that may be required before or after the reconstruction.
- Any physical issues, including lymphedema, at any stage of the mastectomy procedure (fluid build-up in the arm and chest on the side of the surgery)
Benefits for mastectomy surgery may have a yearly deductible and require you to pay some out-of-pocket expenses.
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.”
How long does breast reconstruction surgery take?
How long does it take to have breast reconstruction surgery? It may take up to two hours to prepare for the surgery, including anesthesia. It will take 1 to 6 hours to complete the reconstruction. You’ll spend roughly 2 to 3 hours in recovery after surgery before being transported to a hospital room.
How soon after mastectomy can you have reconstructive surgery?
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 extra liquid is given 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 every breast cancer is different, so is every reconstruction operation and its timing. 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 assist you in determining the best time 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 accessible in your region 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.
How long are you in hospital after a mastectomy?
Mastectomies are a relatively safe treatment with few risks. The majority of people recover quickly and only need to stay in the hospital for one night. Some people, however, will need to stay in the hospital for a few days. In most cases, full recovery takes 3 to 6 weeks.
You may have tubes coming out of the wound in the early stages of recuperation. These are used to drain blood and fluids from the body in order to avoid edema and infection. A dressing will be applied to your scar and stitches.
Pain, numbness, tingling, and swelling are frequent side effects of a mastectomy, although pain relievers can help.
More significant consequences, such as wound infection and delayed healing, can occur in rare situations after a mastectomy.
How is breast reconstruction done after mastectomy?
You may have had or be having a mastectomy, either because you have been diagnosed with breast cancer or because you are at a high risk of developing it in the future. If this is the case, your doctor may have discussed possibilities for reconstructing your breast or breasts, a procedure known as breast reconstruction. Breast reconstruction is typically done after or shortly after mastectomy, or in certain situations, lumpectomy. After a mastectomy or lumpectomy, breast reconstruction can be done months or even years afterwards. A plastic surgeon produces a breast form with an artificial implant (implant reconstruction), a flap of tissue from another part of your body (autologous reconstruction), or both during repair.
You can’t forecast how you’ll react to losing a breast based on your age, relationship status, sexual activity, or orientation. It’s natural to feel nervous, unsure, sad, and sorrowful about giving away a part of your body that was a key part of your sexuality, what made you look good in clothes, and how you might have nourished your children. That is something that no one can ever take away from you. Moving forward, you now have the option of choose what you want to happen next. But, in order to figure out what is best for you, you must first conduct some thorough thought and delving into your feelings. We’ll go through each of the reconstruction options, what’s involved, and potential concerns, as well as alternatives to reconstruction, in this part.
Asking yourself the following questions might help you begin to consider what type of reconstruction you desire, if any at all:
- Are you willing to have additional surgery for breast reconstruction following a mastectomy or lumpectomy?
It’s also crucial to note that, while breast reconstruction restores the contour of the breast, it does not restore breast or nipple sensation. The skin over the reconstructed breast may become more sensitive to touch over time, but it will never be as sensitive as it was prior to surgery.
- Plastic surgeon Frank J. DellaCroce, M.D., FACS, co-founded the Center for Restorative Breast Surgery and the St. Charles Surgical Hospital in New Orleans, LA.
- Plastic surgeon Scott K. Sullivan, M.D., FACS
co-founder of the St. Louis Breast Center and the Center for Restorative Breast Surgery
New Orleans, LA’s Charles Surgical Hospital
- Beth Baughman DuPree, M.D., FACS, is the medical director of the Holy Redeemer Health System’s Breast Health Program and the chairperson of the American Society of Breast Surgeons’ Board of Advocates.
- Steven J. Kronowitz, M.D., FACS, is an associate professor of plastic surgery at the University of Texas M.D. Anderson Cancer Center’s Department of Surgery.
- Dahlia Sataloff, M.D., FACS, is a clinical professor of surgery at the University of Pennsylvania School of Medicine, as well as the director of the Comprehensive Breast Center and vice chairman of the Department of Surgery at Pennsylvania Hospital.
- Plastic surgeon Robert Allen, M.D., is the founder of The Center for Microsurgical Breast Reconstruction and the Group for the Advancement of Breast Reconstruction. He is also a clinical professor of plastic surgery at NYU Medical Center, Medical University of South Carolina, and LSU Health Sciences Center.
To read some of our Discussion Board members’ tales, click here.
Visit our Member Stories: Members Sharing Their Reconstruction Decisions site to hear from community members about their reconstruction decisions.