Breast reconstruction procedures should be covered by your health insurance plan, whether they are done right away, soon after mastectomy/lumpectomy, or many years later. This includes procedures that may be needed over time to refine the reconstructed breast and/or to create symmetry (balance) between the two breasts.
The Women’s Health and Cancer Rights Act of 1998 requires all group health plans that pay for mastectomy to also cover prostheses and reconstructive procedures. In addition, Medicare covers breast reconstruction, while Medicaid coverage can vary from state to state. Government- and church-sponsored plans are not necessarily required to cover reconstruction, so you may need to check with your plan administrator.
Even if you’re covered, it’s still possible to run into problems, especially in certain situations: for example, maybe you’ve chosen a newer type of reconstructive procedure, you’re having surgery to create a more balanced appearance, or you need a complete correction of a past reconstruction. Coverage also can be an issue if you want to use a plastic surgeon who is outside your health insurance plan’s network.
It’s always best to communicate with your health insurance provider up front and check on what exactly is covered so you can avoid the work of trying to get payment later. You also can work with the administrator in your plastic surgeon’s office who handles insurance claims. Another potential resource is your state health insurance agency and commissioner, as some states have passed additional laws requiring coverage for breast reconstruction.
These are some questions you can use to guide these initial conversations with your insurance plan and plastic surgeon’s office:
- Does my plan cover mastectomy? (If the answer is yes, it must cover reconstruction.)
- How many “second” opinions are covered?
- How should I obtain preauthorization for my surgery?
- Am I limited to in-network surgeons and services?
- If I travel to another surgeon who specializes in a particular technique not available within my network, what expenses will be covered?
- What are my total out-of-pocket costs if I go to an out-of-network surgeon?
- Is there a limit to the amount of coverage provided?
- Is my hospital stay covered? If so, for how many days?
- Are the other healthcare professionals involved in my surgery covered?
- Will all payments be made directly to providers?
Source: Kathy Steligo,The Breast Reconstruction Guidebook (Baltimore: The Johns Hopkins University Press, 2017), p. 207-208.
Remember that you’ll still be responsible for your deductible and co-pays, so make sure you understand how much you’ll be paying out of pocket. If you’re responsible for a portion of the treatment cost, this might influence your decisions about what type of reconstruction to have. Costs can vary widely, but implant procedures generally do cost less than tissue flaps. However, they’re more likely to require adjustment in the future, so the overall cost may even out.
How your plastic surgeon’s office communicates with the insurance company about your surgery can make a major difference, too, says Frank J. DellaCroce, M.D., FACS, plastic surgeon and co-founder of the Center for Restorative Breast Surgery. The office must use language that clearly indicates it is medically necessary, not just cosmetic. “If you’re fixing a reconstructed breast that has become misshapen, for example, or bringing the two breasts into balance, there is a potential for the insurance plan to deny coverage right away and say, ‘Well, that’s cosmetic.’ Instead we might have to say, ‘Acquired asymmetry in the breast after mastectomy that was causing a cup size difference that gives difficulty in clothing and function, and she has an overall imbalance that is producing a deformity with respect to symmetry.’ When you lay it out like that, then they have a harder time saying well, too bad. It becomes more real."
Dr. DellaCroce offers these other tips:
- Make sure the office is using the language specified in the ICD-9 (soon to be ICD-10) code, which is the standard classification system that all insurance plans follow.
- Be persistent. If coverage is denied, you and your physician’s office can revise the description and send a non-identifying photo (your chest only, not your face) to illustrate the problem area(s).
- Keep complete print records of every communication as you push forward with your case.
“We usually have success, but the way that the physician’s office communicates the issue to the insurer will either guarantee success in terms of coverage or will guarantee denial,” Dr. DellaCroce adds.
For more detailed information about how to make an appeal to your insurance provider, we recommend chapter 19 of Kathy Steligo’s book, The Breast Reconstruction Guidebook. This chapter offers great tips about how to go about this process. To learn more about your rights under the Women’s Health and Cancer Rights Act, check out the American Cancer Society’s helpful Women's Health and Cancer Rights Act page, including the questions and answers.
You can also read our blog, Reconstruction Coverage Under the Women’s Health and Cancer Rights Act.
For additional tips about managing your health insurance and treatment-related costs, visit Breastcancer.org’s section on Paying for Your Care. This section focuses more on breast cancer treatments, but some of the advice still may be helpful to you.