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 do I get insurance to cover breast implants?
First and foremost, health insurance providers are interested in the original reason for your breast implants (as well as Medicare and Medicaid).
If your implants were placed after a mastectomy and your doctor thinks they should be removed, “The Women’s Health and Cancer Rights Act of 1998 requires your health insurance to fund your breast implant removal if it is “medically necessary” (WHCRA).
If you got breast implants for the purpose of enhancing your healthy breasts, certain health insurance companies will pay your explant surgery if they judge the services to be necessary “Medically required.”
How much does breast reconstruction cost?
- 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.
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:
How much does a mastectomy cost without insurance?
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 implants after weight loss?
While most plastic surgery operations are deemed elective and are not covered by insurance, a body lift or bariatric surgery may be. Body lift surgery may be covered by your insurance because it is frequently performed for medical and sanitary reasons in addition to aesthetic reasons. While insurance coverage varies by company, the first step in considering body lift surgery is to call your insurance provider and learn about your coverage possibilities.
How do you pay for breast implants?
Breast augmentation financing might help you get the look you’ve always wanted without breaking the bank. However, like with any financial decision, it’s important to understand your alternatives as well as your obligations so you can make the best decision and prevent unpleasant surprises.
The eight most common ways to pay for breast augmentation surgery are shown below. Keep in mind that the payment options are displayed from most expensive to least expensive.
Your Surgeon’s Payment Plan
While some plastic surgeons provide financing options, many rely on third-party financing organizations to handle their finances.
Low monthly payment options and extended payment options are common features of these programs, making them desirable. Fees and interest rates are competitive, albeit they can occasionally be higher than those offered by traditional credit cards.
It’s critical to make all of your payments on time if you choose one of these programs. You may be subject to a higher interest rate or a penalty based on your balance if you miss or are late with a payment.
Personal Credit Cards
A typical method of financing a breast augmentation treatment is to use a personal credit card.
To pay for your surgery, look for a personal card with a 0% APR offer. Alternatively, you can pay for it using a rewards credit card and earn points or cash back.
Credit cards are notorious for having hefty interest rates. If you can’t get a 0% APR loan, you can find up spending a lot more for your surgery than you planned for. Furthermore, the hefty charge on your card is likely to tie up your credit, lowering your credit utilization and maybe lowering your credit score.
Medical Credit Cards
Another frequent method of financing breast augmentation is to use a medical credit card. It’s crucial to make sure you don’t miss any payments or make any late payments, or you could face a higher interest rate or penalties, just like with other types of financing.
Personal Loans
An unsecured personal loan, whether from a bank or a credit union, is a convenient and quick option to fund your breast augmentation procedure. for the purpose of a surgical procedure Personal loans feature a fixed interest rate and a specified repayment period.
Pros: When compared to some of the other financing options described below, an unsecured loan may be the most cost-effective way to obtain the operation you want. A bank loan will almost certainly have a lower interest rate than a credit card if you have a good credit history. Another advantage of an unsecured loan, which you may not want to explore, is that if you have a financial disaster, your debt can be erased in a Chapter 7 bankruptcy.
Cons: Because of the interest you’ll pay over time, a personal loan is likely to increase the cost of your treatment. So, while you’ll be able to have the body you want right now, you’ll end up paying more money in the long run. If your credit isn’t excellent, you’ll probably get a rate that’s similar to that of a credit card, which isn’t necessarily the best offer.
Home Equity Loan (HELOC)
A home equity loan or line of credit translates the equity you’ve built up in your home into cash that you may use to pay for your breast augmentation treatment.
Pros: Because interest rates are based on actual mortgage rates, you’re likely to get a good deal right now. It’s also possible that your interest will be tax deductible.
Cons: No one wants to lose their home’s equity. When you spend up your equity, you’re essentially beginning over with the purchase of your home. You could end yourself with negative equity in your property if the housing market takes a turn. In the unfortunate event that this occurs and you are forced to sell your home, you may find yourself in a very terrible financial situation. Before you use your home equity to fund your plastic surgery, think about this.
Family Loans/Gifts
Your family or friends may be willing to lend you money for surgery. Some patients have been successful in raising enough money for their breast augmentation surgery by enlisting the help of family and friends.
Advantages: There aren’t any interest rates. Friends and relatives can also provide social and emotional support.
Cons: Asking for a loan or suggesting plastic surgery as a gift may be challenging or unpleasant.
Retirement Account/401(k) Loans
You may be able to borrow up to 50% of your vested 401(k) amount, up to a maximum of $50,000, from your 401(k) account. Your loan repayment is withdrawn from your paycheck automatically. The loan can be repaid over a five-year period.
Pros: Taking out a loan from your retirement plan is usually simple and quick. Typically, interest rates are low.
Cons: Withdrawing funds from a retirement account and incurring tax and penalty consequences is not a popular option. Your money will essentially be taxed twice. You’ll miss out on some asset growth until the loan is paid off if your retirement plan doesn’t allow contributions until the debt is paid off. You’ll have 60 days to pay off your loan if you choose to leave your employment or lose it for whatever reason, or you’ll have to claim it as a distribution if you don’t (more taxes and penalties).
Savings
If you have money in the bank, you can always use it to pay for your breast augmentation surgery using the money you’ve saved.
Cons: Many people are hesitant to pay for plastic surgery with money they’ve set aside for emergencies. In the event of a serious emergency, having less cash on hand could put you in jeopardy. This risk may be lessened if you have alternative financing choices available.
Does insurance pay for capsular contracture?
Insurance companies typically consider breast augmentation to be an elective cosmetic surgical treatment, and it may or may not be covered under health coverage. However, health concerns associated with breast implants, such as capsular contracture, are frequently classified as medical rather than cosmetic.
The patient should contact her insurance provider to learn more about her unique insurance policy’s coverage for breast capsulectomy. Dr. Hisham Seify, a board-certified plastic surgeon, performs breast implants and other treatments for patients in Newport Beach, Orange County, and the surrounding areas.
Insurance Eligibility
Patients should be aware that in order for a breast implant plastic surgery complication to be covered by insurance, it must be more than just an aesthetic concern, such as asymmetry, implant rippling, or an undesirable implant size or form. If left untreated, the breast implant problem must constitute a direct threat to the patient’s health. The breast capsulectomy operation may be covered by insurance only if certain conditions are met.
If the capsular contracture is severe, it will be classified as a major breast implant problem with serious health consequences if left untreated. As a result, receiving insurance coverage for breast capsulectomy surgery may be achievable. Dr. Seify is a top cosmetic surgeon in Newport Beach, Orange County, California, who performs breast capsulectomy and other treatments on patients.
Proper Documentation
While there is no assurance when it comes to gaining insurance coverage for breast capsulectomy surgery, appropriate paperwork can help to boost the odds of coverage. Spending the time and effort to organize proper papers that detail the exact nature of the illness from the moment the first symptoms appeared is worthwhile.
The patient must work with the plastic surgeon’s office to arrange for accurate and adequate medical documentation that defines the problem and outlines the risks to the patient’s health if it is not treated.
Degree of Capsular Contracture
It is critical to define the degree of capsular contracture in the documentation in order to secure insurance coverage. The Baker Scale is one of the most common methods used by insurance companies to decide whether or not a woman is eligible for a breast capsulectomy. If the capsular contracture is classified as Grade 1 or 2, the insurance company is unlikely to consider it severe enough to merit coverage.
Grade 3 or Grade 4 capsular contracture, on the other hand, might produce pain, visual deformity, and potentially obstruct clear mammography results. In such circumstances, insurance companies would frequently cover breast capsulectomy surgery to alleviate the problem.
Payment for Specific Procedures
Even if an insurance company agrees to cover breast capsulectomy, they may only cover the portion of the procedure that involves implant removal and scar tissue removal. They normally won’t pay for the replacement of old breast implants with new ones, or for the replacement of the original implants, because it won’t have a direct influence on the patient’s health. Even if it improves their psychology, self-confidence, and, possibly, money!
Dr. Hisham Seify, a plastic surgeon in Newport Beach, offers a variety of operations and treatments.
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 procedure. 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.