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.
What qualifies as breast reconstruction?
Breast reconstruction frequently entails a series of treatments that can either begin at the time of mastectomy or be postponed until a later date.
Implant-based reconstruction and flap reconstruction are the two most common types of breast reconstruction. Breast implants are used in implant reconstruction to help build a new breast mound. Flap (or autologous) reconstruction replaces a patient’s breast with tissue from another section of the body.
When deciding which choice is better, there are several aspects to consider:
What insurance covers breast implants?
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.
How much does a double mastectomy with reconstruction cost?
What Is the Price of a Double Mastectomy? A Double Mastectomy costs between $2,944 and $17,730 on MDsave. Those with high deductible health plans or those who do not have insurance might save money by purchasing their procedure in advance with MDsave. Learn more about MDsave’s operation.
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.”
Will insurance cover a preventative 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.
Can you have breast reconstruction without implants?
A pedicle flap used for breast reconstruction is the latissimus dorsi flap. This sort of flap is frequently utilized with a breast implant to increase volume (size) to breast reconstruction because there is usually not as much tissue there as from an abdominal wall (tummy) donor site. The surgeon tunnels muscle, fat, skin, and blood arteries from your upper back through the skin to the front of your chest for this treatment. Depending on the amount of tissue and desired breast size, this sort of reconstruction can sometimes be performed without the use of an implant. Despite the fact that the flap removes one muscle from the back, women rarely experience weakness in their back, shoulder, or arm as a result of the procedure.
Pedicle back flaps that do not require any muscle are also available. The thoracodorsal artery perforator (TDAP) flap removes the upper back skin and fat but not the muscle. When needed, it’s frequently utilized for reconstruction after a lumpectomy or partial mastectomy.
If there isn’t enough abdominal wall (tummy) tissue to utilize as a donor site, a newer operation called a lumbar artery perforator (LAP) free flap may be an alternative. The skin, fat, and blood vessels in the lower back (commonly known as “love handles”) are removed and transported to the chest, where the blood vessels are reconnected. There is no muscle removal. The LAP free flap can only be performed on one side at a time (one breast at a time), requires an additional step to reconnect the blood arteries, and is only available at a few hospitals in the United States.
Can belly fat be used for breast reconstruction?
Autologous breast reconstruction treatments use a flap of tissue from another region of the body to rebuild a breast mound instead of implants. Historically, surgeons have moved skin, fat, and occasionally muscle from the inner thigh (TUG Flap), back (Latissimus Flap), and buttock area (SGAP Flap).
The lower tummy is now the most common donor site. Excess belly fat can be used in breast reconstruction to provide natural-looking results.
Many individuals have enough extra fat in this location to make the operation possible. Patients also benefit from a smaller waistline after the fat is eliminated in a similar fashion to a stomach tuck.
DIEP Flap is a technique for autologous breast reconstruction. It is a muscle-sparing approach that preserves the integrity and strength of your abdominal wall as compared to other flap procedures. It also necessitates a faster recovery time.
As a result, at The Breast Center Park Meadows Cosmetic Surgery, the DIEP Flap is our preferred technique. All suitable patients who are interested in autologous reconstruction should consider it.
Why You Should Choose Our Breast Reconstruction Surgeons
Completing the DIEP Flap requires a high level of skill. As a result, only a few surgeons provide it.
This operation is performed by about 60 doctors in the United States (less than 5% of all plastic surgeons). We are fortunate to have two surgeons on our team who are experts in the DIEP Flap technique.
Our team works hard to make the procedure as simple as possible for you. 95 percent of our patients are discharged from the hospital two days following their treatment at The Breast Center Park Meadows Cosmetic Surgery. This is a far shorter stay than the four or five days that are typical elsewhere. Furthermore, our DIEP flap failure rate is less than 1%, which is significantly lower than the national norm.
Schedule a Consultation in Lone Tree
Many women want to have their breasts reconstructed using belly fat. During a consultation, find out if this method is correct for you. To arrange a visit to our office, call 303-706-1100 today. Patients come from all across the country, including Denver and Lone Tree, Colorado.
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 do people afford plastic surgery?
When you’re looking for a plastic surgeon to complete your medical operation, find out if they provide any type of financing or payment plan. You might be able to spread the expense of your cosmetic operation across several months without paying interest.
Many surgeons, on the other hand, avoid getting involved in the financial aspects of the process and instead rely on third-party financing solutions such as medical credit cards and plastic surgery loans.