Will My Insurance Cover Breast Reconstruction?

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.)

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.

Is breast reconstruction after cancer 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.

How much is breast reconstruction surgery without implants?

Breast reconstruction employing “flap” techniques (using tissue from the patient’s own body to build new breasts) often costs $25,000 to $50,000 or more per breast, or $50,000 to $100,000 for both sides if the patient does not have health insurance.

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.

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.

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.

Does insurance pay for uneven breasts?

Breast revision surgery is a treatment or set of operations used to improve or repair a previous breast surgery’s unsatisfactory outcome. This could be due to age-related changes in the body altering surgery outcomes, your body responding in an unanticipated way throughout the healing period, or simply a desire for a new look.

Breast revision surgery can treat a variety of difficulties from a previous procedure, such as implant placement issues or unequal breasts (asymmetry), scar improvement, reducing excess scar tissue surrounding the implants (capsular contracture), and implant replacement, removal, or modification. Regardless of why you needed revision surgery in the first place, the goal of breast revision surgery is to offer you beautiful, natural-looking outcomes.

Patients who are considering breast revision surgery are concerned about whether their insurance would cover the treatment. Breast revision surgery is frequently covered by health insurance companies, especially if it is linked to:

How much is a mommy makeover?

Let’s start with a basic explanation of what a mommy makeover is and what it comprises in most cases.

Even the healthiest mothers who strive tirelessly to regain their pre-pregnancy figures discover that the effects of pregnancy are irreversible and cannot be exercised away. When the body is stretched and tugged, excess skin is left behind, and the swelling and subsequent shrinking of the breasts can leave them flat and sagging.

‘Mommy makeover’ is an old phrase for a sequence of surgeries that surgically restores the pre-baby shape as closely as feasible. A mommy makeover is, at its most basic level, any breast surgery combined with any abdominal surgery. You can reduce recuperation time and get back on your feet faster by doing both procedures at the same time.

A mommy makeover consists of a breast procedure combined with one of the following body surgeries:

Breast augmentation

Breast augmentation may be the perfect decision if your breasts have lost volume or are sagging more than you would like. You can walk away with either saline- or silicone-filled implants after a one- to two-hour operation. Although breast implants are a permanent treatment, they may need to be changed after a few years.

While it’s important to have a basic awareness of the other aspects that determine the cost of a breast augmentation, the breast implant you choose is one of the most important. The cost of breast augmentation surgery varies depending on the patient’s surgical goals and needs.

When comparing the cost of silicone versus saline breast implants, consider the look and feel you want to attain. Would you prefer a substance that is a little firmer but has a similar composition to the fluid that makes up the majority of the human body for a more natural look and feel, or would you prefer a substance that is a little firmer but has a similar composition to the fluid that makes up the majority of the human body?

  • Breast implants made of silicone gel are more expensive because they are filled with a cohesive gel that holds together uniformly while keeping the natural give of breast flesh. To ensure uniform fill quantities, the manufacturer prepares these and tests them for quality. Because there are various distinct types of silicone implants, the cost each implant varies. There are various silicone implants, such as ‘gummy bear’ or’shaped’ implants, that are more expensive than traditional round silicone implants. Austin-Weston surgeons provide every commercially available breast implant available in the United States.
  • Because they are filled with a saltwater solution similar to the fluid that makes up the majority of the human body, saline-filled breast implants are less expensive, but they are slightly stiffer to the touch and are filled by the surgeon during the breast augmentation operation.

Breast lift

If the idea of implants makes you feel uneasy, a breast lift may be the way to go for a mommy makeover that restores that desired young shape and appearance. Perky breasts don’t have to be a thing of the past; this technique provides an alternative to re-inflating sagging, droopy, or improperly formed breasts. Excess skin is removed, breast tissue is elevated, and nipples and areolae are repositioned or even shrunk.

Temporary discomfort, swelling, bruising, and scarring, similar to breast augmentation, are possible adverse effects. The treatment might take anywhere from an hour and a half to more than three hours, but the good news is that the benefits are long-lasting. You can’t entirely stop gravity, but you can put it on hold for a while. In one to two weeks, most patients should be able to return to work.

Breast augmentation with lift

Because the breasts tend to spread and lose shape and volume after pregnancy, many women who have had children are great candidates for a combination breast augmentation with concomitant complete lift. This surgery, on the other hand, can be advantageous for any woman who wishes to increase the size of her breasts while also reducing breast sagging.

Breast Reduction

Women who have pain in their backs, necks, and shoulders, or who have indentations in their bra straps, may benefit from a breast reduction. A breast reduction can also help women who seek a lower breast size and better breast form.

Tummy tuck

An abdominoplasty, often known as a stomach tuck, is a treatment that takes two to five hours to complete. Your surgeon will remove superfluous skin, realign your navel, and tighten your abdominal wall to give your weak abdominal muscles new vitality.

A belly tuck leaves a scar, and recovery is lengthy — you can return to work and motherhood in one to three weeks, but it could take longer depending on your physical condition. The end result, though, can be a much flatter tummy and a much slimmer waist.


Although liposuction is referred to as “body shaping,” the surgery is far from glamorous. Having fat pulled out of your body isn’t as glamorous as it sounds, but the benefits can be incredible and immediate. If you’ve ever seen liposuction on TV, you know how brutal it can be. However, there are newer ways that alleviate some of the pain by melting the fat using ultrasound first.

Keep in mind that liposuction is not a substitute for weight loss. It can, however, help to get rid of stubborn fat that refuses to respond to diet and exercise. This means that you shouldn’t be surprised if your doctor advises you to reduce additional weight before undergoing this treatment.

The procedure might take anywhere from 45 minutes to two hours, depending on how much area you want liposuctioned. Bruising, pain, and even numbness are possible side effects, but the final contour is usually seen after three months. You should be able to return to work in one to two weeks, but you should plan on wearing a compression garment for up to six weeks to encourage your skin to contract and reduce swelling.

Mommy makeover statistics

It’s vital to remember that the price of a mommy makeover varies greatly from one patient to the next and frequently excludes other surgery-related costs. The surgeon’s charge, facility fee, anesthesia fee, post-surgery fees, and implant cost are the key costs that go into your total.

So, to give you a quick response, the total cost of a mommy makeover surgery can range from $9,000 to $20,000.

However, the final cost will be determined by a number of factors and variables, including:

Surgeon selection

Because they have varied amenities at their disposal and varying degrees of experience and accreditations, all surgeons have their own technique to executing mommy makeovers.

It’s reasonable to believe that choosing a surgeon has the greatest impact on the entire cost of surgery. Our four board-certified plastic surgeons at Austin-Weston, The Center for Cosmetic Surgery, for example, have a combined 75 years of experience and have built a solid reputation in Northern Virginia and the DC Metro area.

We can only speak for ourselves when we say that each operation is preceded by a thorough consultation including computer analysis and imaging technologies, as well as the expert eye of our surgeons, to ensure that we provide our patients with satisfactory and life-changing outcomes.

Geographic location

Plastic surgery expenses vary based on geographic locations, such as big urban centers, because physicians in these areas have higher overhead costs. So, the first step in determining how much you’ll pay is to look at the fees in your location and the cost of living there.

Using the Healthcare Blue Book to get a ballpark price for treatments depending on location (it works the same way Kelley Blue Book lists the prices of cars).

Surgical facility

The surgical facility is an important consideration not only because of the overall expense, but also because it may place a value on your safety and satisfaction.

In the decision-making process, it’s vital to have your surgery performed in an accredited surgical facility by qualified staff. Don’t try to save money by having your surgery done at a non-accredited facility or by a surgeon who isn’t certified by the American Board of Plastic Surgery.

The Austin-Weston Center is a stunning free-standing surgery center in Reston, Virginia, with five operating rooms. The Accreditation Association for Ambulatory Health Care (AAAHC), an organization that accredits office-based surgical facilities, has fully accredited our state-of-the-art facility.

Our surgeons are fully insured and board qualified in plastic surgery, and our Certified Nurse Anesthetists (CRNAs) are nationally certified by the Council on Certification of Nurse Anesthetists. Additionally, all of our staff is licensed and certified in Advanced Cardiac Life Support (ACLS).

Surgery-related expenses

You should inquire directly with the surgeon if these are the total fees included in your estimate. Because there is no predetermined dollar amount for such expenses, it is vital to weigh your options by consulting with a number of surgeons and obtaining estimates for not only their physician fees but also any additional surgical-related costs.

Make careful to factor in the following surgery-related costs when calculating the cost of a mommy makeover:

Anesthesia fees

Anesthesia costs for mommy makeover surgery can also differ. The cost will be higher if you use a board-certified anesthesiologist. The cost will be less if you use a CRNA (nurse anesthetist). Another cost-cutting factor is when a doctor uses a non-certified anesthetist nurse or a medical assistant to administer anesthetic medications (and yes, unfortunately, this does happen). Anesthetic fees are charged by the hour, so if the surgeon takes his time to provide the best possible results, the anesthesia fee would be greater. This can also vary based on the surgical approach employed, which can take longer or shorter depending on the circumstances.

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.