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.
Does insurance cover breast reconstruction after a mastectomy?
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 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 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.
Does insurance cover preventative mastectomy and reconstruction?
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 a mastectomy considered major surgery?
- The treatment entails the permanent removal of one or both breasts, which is a significant risk factor in and of itself.
- Depending on the severity of the ailment, the process can take up to four hours.
- Depending on their recovery rate, patients may need to stay in the hospital for a few days.
Do you get to keep your nipples after a mastectomy?
When a mastectomy is used to treat breast cancer, the nipple is usually removed along with the rest of the breast. (Some women may be able to have a nipple-sparing mastectomy, which leaves the nipple intact.) This is covered in greater depth on our mastectomy page.)
If you’re having breast reconstruction following a mastectomy, you can choose whether you want the nipple and the dark area around it (areola) to be reconstructed using surgery, tattooing, or both.
What’s the average cost of a mastectomy?
Breast cancer may necessitate a mastectomy in some women. This procedure is costly on its own, therefore it’s often combined with chemotherapy. The treatment costs around $13,000 on average, not including any kind of reconstruction.
Do reconstructed breasts have feeling?
Breast reconstruction surgery should result in a balanced appearance (also known as breast symmetry). You want to seem and feel balanced. Breast reconstruction procedures and timing are continually being refined by plastic surgeons to guarantee that the results are both physically and emotionally satisfactory. Even so, there’s a chance you won’t be completely delighted with your breast reconstruction outcomes.
Size, position, angle, and balance of your new breast or breasts may not meet your expectations. They might not be as silky or natural-feeling as you expected. In a breast that has been repaired with an implant, you will likely experience no sensation and little sensation in a breast that has been reconstructed with autologous tissue.
Asking your medical staff a lot of questions about what to expect is one of the best ways to ensure that you’re completely satisfied with your reconstructed breast. Even before your first mastectomy incision, this is crucial since the placement and “design” of the incision might affect your reconstructive results. Inquire for photos of breast reconstructions that your surgeon has completed. You can also inquire about the names of ladies who have undergone the treatment you’re considering with your surgeon. You might find it beneficial to speak with another woman about her decision-making process, doctors, and satisfaction with the outcomes.
A woman’s happiness with her breast reconstruction results appears to be influenced by a number of factors:
- Size: The reconstructed breast may be slightly larger than the other breast following surgery. This is due to surgery-related edema. The swelling of the reconstructed breast will go down as it heals, and the reconstructed breast will be closer in size to the other breast. If the size discrepancy is still obvious, your surgeon can remove fat from the reconstructed breast.
- Weight increase: If you gain or lose weight, a breast that has been reconstructed with an implant does not gain or lose weight. If you have implant reconstruction and gain weight afterward, you and your surgeon may decide to replace your initial implant with a larger one to help your breasts regain equilibrium. Because a breast that has been repaired with a flap operation gains and loses weight with the body, this is less of a concern. Significant weight gain (or decrease) may, however, cause an imbalance between the rebuilt and natural breasts.
- Drooping or sagging: It’s difficult to replicate your original breast’s natural droop. With time and gravity, a breast repaired with an autologous technique may sag, whereas a breast reconstructed with an implant rarely sags. Your other breast may sag with time, but the reconstructed breast will remain higher and firmer. When you’re wearing a bra or swimming suit, it might not bother you, but when you’re naked, it might. If it does, your surgeon will likely find it much easier to decrease and raise your other breast to match the reconstructed one. See Altering the Opposite Breast for further details.
- Changes in breast sensation: When you or someone else touches your reconstructed breast, it will feel quite similar to your natural breast. Even so, you’re unlikely to feel much feeling in your breast when it’s touched. This is due to the fact that the majority of the nerves in the area are cut during mastectomy and reconstruction, causing the area to go numb. For women whose breasts were an essential erogenous zone, this can be concerning. The nerves have the ability to regrow, but it takes a long time. You may experience tingling or other feelings in your breast if the nerves begin to regenerate. If any sensation in your breast returns, it’s likely that you’ll notice something in a year or two. If you lose feeling in your breast, it’s possible that you’ll regain it in the area next to your breast. Some women discover that the armpit close to the reconstructed breast becomes extremely sensitive to touch, indicating the presence of a new erogenous zone.
Talk to your surgeon and other members of your medical team if you’re not happy with your reconstructed breast as much as you expected. There may be things you and your team may take to improve the reconstruction’s appearance and feel. Find out more about the benefits of corrective breast reconstruction.
Watch the movies below to learn about two women who suffered issues from their initial surgery and elected to have corrective breast reconstruction.
Corrective Breast Reconstruction: Caren’s Story
Caren had a double mastectomy with implant reconstruction after being diagnosed with breast cancer. Her surgeon offered her D-cup implants despite her desire for B-cup breasts. Her ability to exercise, date, and feel good about herself was harmed as a result of complications and subsequent surgery. Then she went to the New Orleans Breast Center and saw Dr. Frank DellaCroce, who did a hybrid stacked DIEP/SGAP breast reconstruction. “I’ll be eternally thankful to the Breast Center, and Dr. DellaCroce is one of my favorite doctors. They returned my life to me.”
Corrective Breast Reconstruction: Peggy’s Story
After a double mastectomy with implant reconstruction, Peggy struggled to accept her new figure. She had a surgery revision with DIEP flaps, nipple reconstruction, and 3D nipple tattooing after one of her implants ruptured. Peggy claims that this operation helped her gain a lot of confidence in her figure.
For more information, listen to the podcast Revision Reconstruction: What You Need to Know.
How long do you stay in the hospital after a mastectomy?
After your mastectomy surgery, you’ll be sent to the recovery room, where nurses will monitor your heart rate, body temperature, and blood pressure. Let someone know if you are in discomfort or sick from the anaesthetic so that you can be given medicine.
After that, you’ll be admitted to a hospital room. The usual length of stay in the hospital for a mastectomy is three days or fewer. You may spend a little longer in the hospital if you get a mastectomy and reconstruction at the same time.
Your surgeon or nurse will show you an exercise plan the morning after your surgery to help avoid arm and shoulder stiffness on the side where you had the mastectomy, as well as the production of considerable scar tissue. Until the drains are eliminated, some exercises should be avoided. To ensure that the fitness plan is correct for you, ask your surgeon any questions you may have. In addition, your surgeon should provide you with written and graphical instructions on how to perform the exercises.
Your surgeon or nurse will offer you information about healing at home before you leave the hospital:
- Taking pain medication: When you leave the hospital, your surgeon will most likely give you a prescription to take with you. You might want to fill it on the way home, or have a friend or family member fill it for you as soon as you get home, so that you have it.
- Taking care of your incision’s bandage (dressing): Inquire with your surgeon or nurse about how to care for your mastectomy bandage. The surgeon may request that you refrain from attempting to remove the bandage and instead wait until your first follow-up appointment so that he or she can do so.
- Taking care of a surgical drain: If you have a surgical drain in your breast or armpit, it may be removed before you leave the hospital. However, a drain may be left in place until the first follow-up appointment with the doctor, which is normally 1-2 weeks after surgery. You’ll need to empty the fluid from the detachable drain bulb a few times a day if you’re going home with a drain. Before you leave the hospital, be sure your surgeon has given you instructions on how to care for the drain.
- Sutures (stitches) are used by the majority of surgeons, and they dissolve over time, so they don’t need to be removed. The end of the suture will periodically poke out of the incision like a whisker. If this occurs, your surgeon will be able to quickly remove it. Surgical staples, which are another method of closing the incision, are removed on the first visit to the doctor following surgery.
- How to tell if you have an infection in your incision and when to call the office: Your surgeon should explain how to tell if you have an infection in your incision and when to call the office.
- Exercising your arm: Your surgeon or nurse may demonstrate an exercise plan to prevent arm and shoulder stiffness on the side where surgery was performed. The exercises will usually begin the morning after surgery. Until the drains are eliminated, some exercises should be avoided. To ensure that the fitness plan is correct for you, ask your surgeon any questions you may have. In addition, your surgeon should provide you with written and graphical instructions on how to perform the exercises.
- Recognizing lymphedema signs: If you’ve undergone an axillary dissection, you’ll be given instructions on how to care for your arm and recognize lymphedema symptoms.
- When you can wear a bra again or start using a prosthesis: Before you can wear a prosthesis or bra, the site after mastectomy surgery, especially mastectomy with reconstruction, needs to recover. Your doctor will advise you on how long you should wait.
Should I get a preventive mastectomy?
Only those women with a very high risk of breast cancer should undergo a preventive mastectomy, according to the National Cancer Institute. Â Women who have one or more of the following risk factors are included in this group:
- Previous breast cancer in one breast and a high risk of breast cancer in the other
- Breast cancer in the family and a history of lobular carcinoma in situ (LCIS)
Preventive mastectomy should only be considered after you’ve had the necessary genetic and psychological counseling to address the procedure’s psychosocial implications.