Insurance Coverage for Breast Reconstruction

April 9, 2014


shutterstock_138113543

shutterstock_138113543

Breast reconstruction can be an important step in the healing process for women who have undergone mastectomies. Unfortunately, studies have shown the percentage of women opting for reconstruction surgery has been traditionally low. In the past, approximately one-fourth of all women undergoing mastectomies have chosen reconstructive surgery. Fortunately, the number of patient’s choosing reconstruction is increasing.

For women that do make the decision to have reconstructive surgery, whether insurance covers the procedures is often a concern. In the past, reconstructive breast surgery was considered by insurance coverage to be “cosmetic.” Luckily, state and federal laws now require insurance companies to cover the costs of breast reconstruction.

Federal Law Details
In 1998, the Women’s Health and Cancer Rights Act (WHCRA) was signed into federal law to ensure insurance coverage for women seeking breast reconstruction after a mastectomy. The law requires health plans to provide coverage for reconstruction surgery for any breast removed by mastectomy.  The reason for the mastectomy does not change the coverage requirement, so women needing mastectomies for any medical reason are protected by this law.

The WHCRA provides for the following:

  • Reconstruction of the removed breast
  • Surgery for the other breast to make breasts symmetrical
  • External prosthesis to be worn before or during reconstruction process
  • Complications that might occur during or after the mastectomy

Insurance companies that provide coverage for mastectomies must also provide coverage for reconstruction surgery. In some cases, reconstructive surgery may also be covered after a preventative mastectomy, if there is evidence to categorize the patient as a high risk for cancer. Companies may institute co-payments or deductibles as outlined in individual plans. However, an insurance company may not assess a higher deductible for breast reconstruction than it does for any other type of surgery.

Additional Protection
In addition to the federal law, some states have their own laws governing reconstruction surgery after mastectomy. These local laws may offer additional protection to patients beyond what is required by the WHCRA. Some states also place time restrictions on when the reconstruction must take place, so it is important to know the state laws when you contact your insurance company about coverage.

Women interested in breast reconstruction surgery should contact their insurance company prior to the procedure to find out precisely what their coverage includes. Surgeons can also verify insurance coverage for patients. To learn more about options in breast reconstruction surgery, contact our staff at Physicians’ Clinic of Iowa, Plastic Surgery at 319-382-8230.

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