models

Does Insurance Cover Breast Reconstruction Surgery? Understanding Your Options

Schedule A Consultation

models

Key Takeaways

Breast reconstruction surgery is typically covered by insurance if your plan includes mastectomy coverage, thanks to the Women’s Health and Cancer Rights Act (WHCRA).
Insurance must cover related procedures, including reconstruction of the affected breast, surgery for symmetry on the opposite breast, prostheses, and treatment of post-surgical complications like lymphedema.
Coverage varies by plan, so it’s essential to review your policy’s specific benefits, restrictions, and any required deductibles or coinsurance.
Pre-authorization may be required, so confirm with your insurance provider before scheduling surgery to avoid denial or delays.
Work closely with your surgeon’s office, which may assist in navigating insurance paperwork and approvals.
You are entitled to receive written notice from your insurer outlining your reconstruction coverage under WHCRA; review this annually to stay informed.
If insurance denies coverage, you can appeal the decision, seek legal support, or explore alternate funding options like payment plans or financial aid programs.

For many women recovering from breast cancer, breast reconstruction surgery is an important part of the healing process, physically, emotionally, and psychologically.

However, a common question that arises after a mastectomy is, “Does insurance cover breast reconstruction surgery?”

At the Sadeghi Center for Plastic Surgery, we believe every woman should have access to the support, resources, and surgical options she needs. Knowing your rights under federal and state law and what your health insurance plan covers can help you make informed choices about your reconstruction journey.

Call us today to schedule a consultation and learn about your reconstructive options!

Young woman in white bra isolated on white background

model

What Is Breast Reconstruction Surgery?

Breast reconstruction surgery is a type of reconstructive surgery performed to restore one or both breasts to a more natural shape, appearance, and size following mastectomy and breast reconstruction procedures.

Mastectomy is the surgical removal of breast tissue, often due to breast cancer, and it can be followed by either immediate or delayed reconstruction.

There are various surgical options, including:

Tissue-based reconstruction using your own tissue (often from the lower abdomen)
Implant-based reconstruction using saline implants or silicone implants
Nipple-sparing mastectomy with nipple reconstruction
Aesthetic flat closure for those who choose not to reconstruct the breast mound

Reconstruction may also include procedures on the other breast to achieve symmetry, such as breast reduction, lift, or augmentation.

Federal Law: Your Right to Breast Reconstruction Coverage

The Women’s Health and Cancer Rights Act (WHCRA) of 1998 is a federal law that requires group health plans and health insurance companies to cover breast reconstruction surgery if they offer mastectomy coverage.

In other words, if your health insurance plan covers mastectomy surgery, it must also cover breast reconstruction surgery and related benefits.

Beautiful naked young woman covering her breast with sketches under it, isolated on a white background, cropped

model

What’s Included in Insurance Coverage for Breast Reconstruction?

Here’s what insurance is expected to cover under the WHCRA:

1. Breast Reconstruction Surgery

This includes the surgeries necessary to rebuild the breast(s) after mastectomy. Whether it’s an implant-based procedure or a tissue flap surgery, your insurance must cover it.

2. Symmetry Surgery

If you have one breast reconstructed, your insurance should also cover surgery to make the other breast match as closely as possible. This is crucial for people who opt for breast reconstruction after a mastectomy on one side but want the other side adjusted for balance and aesthetics.

3. Prostheses

If breast reconstruction isn’t the right choice for you or if you’re in the process of reconstruction, insurance also covers prosthetic devices (like breast forms) that help fill the void left by the mastectomy.

4. Treatment of Physical Complications

Some people experience issues like lymphedema after a mastectomy. Your insurance should also cover the treatment of complications that arise from the mastectomy, as these can be directly linked to the removal of the breast tissue.

So, the short version? You’re covered for surgery, implants, and prostheses. However, as with any insurance situation, there are things to keep in mind.

model

What You Need to Know to Make Sure You Get Covered

While the law says that breast reconstruction must be covered, there are still steps you need to take to make sure you don’t end up footing the bill yourself.

1. Check Your Plan’s Details

Not all health insurance plans are the same. Some plans may have restrictions on which types of reconstruction surgeries they cover or how much they’ll pay. It’s important to check the fine print of your policy to understand what is and isn’t covered.

2. Understand Deductibles and Coinsurance

Even though the reconstruction itself is covered, that doesn’t mean it’s totally free. Health plans can still impose deductibles or coinsurance, the portion of the cost that you’re responsible for.

These costs are typically in line with the amounts you pay for other medical services under your plan. So, you might end up paying out-of-pocket costs depending on your plan’s terms.

3. Get Pre-Authorization if Necessary

Some health insurance companies require pre-authorization for certain procedures. Before you go ahead with your breast reconstruction surgery, it’s worth confirming with your insurance provider that you have their approval. This will help avoid surprises down the line.

4. Consult with Your Surgeon and Insurance Company

Work closely with your surgeon to ensure they understand your insurance requirements. Your surgeon’s office may even have a team member who helps with insurance paperwork and pre-authorizations. The more your medical team knows about your insurance plan, the better the chances of smooth coverage.

5. Written Notice

Your insurance plan is required by law to provide written notice of your benefits under the WHCRA. This notice should be given to you when you first enroll and annually after that. Make sure to keep these notices and review them each year to ensure your coverage hasn’t changed.

Lost in thoughts. Beautiful young woman in lingerie and white socks looking through a window at home

model

What Happens If You Don’t Get Coverage or Your Insurance Denies It?

Unfortunately, there are instances where insurance may deny coverage for breast reconstruction surgery, even when it’s supposed to be covered.

If this happens, there are steps you can take.

1. Appeal the Denial

If your claim is denied, you have the right to appeal. Make sure to review your insurance policy to understand the reason for the denial and gather any supporting documentation that could help in your appeal.

2. Get Legal Help

In some cases, seeking legal advice may be necessary. If your insurer is not complying with the law, you might have legal recourse. The Employee Benefits Security Administration (EBSA), which enforces the WHCRA, can help if your rights are being violated.

3. Consider Alternative Funding Options

If insurance won’t cover your surgery, you might need to explore other funding options. Some hospitals or medical providers offer payment plans, and there may be charitable organizations or financial assistance programs that can help cover the costs.

Wrapping It Up: Know Your Rights and Options

Breast reconstruction is an important part of recovery for many people following a mastectomy. Thankfully, insurance typically covers breast reconstruction, thanks to the Women’s Health and Cancer Rights Act.

However, understanding the ins and outs of your insurance plan, what’s covered, what’s not, and how to ensure everything goes smoothly is important.

Whether you’re considering reconstruction immediately after mastectomy surgery or years after cancer treatment, you deserve compassionate guidance and professional care. At Sadeghi Center for Plastic Surgery, we are here to help you explore the best options for your body and your recovery.

Contact us today to schedule your personalized consultation!