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By IHPL - July 2, 2020 “Will my insurance company pay for that?” I’m surprised how often I get asked this question. I’ve been a breast surgeon for over 20 years and have had the privilege of taking care of many women who have breast cancer. While most women who have breast cancer today are able to save their breast with successful treatment of their cancer, in some cases, women choose to or must have their entire breast removed in a procedure called a “mastectomy.”1 In other cases, when someone is born with a rare cancer-causing gene (like BRCA1 or BRCA2), her risk of developing breast cancer is so high that we may recommend that she have her breasts removed to prevent developing breast cancer in the future. The loss of one’s breast is obviously life-changing and, for some women, can have profound effects on self-esteem, body image, and sexuality.2 Fortunately, surgical techniques to remove a woman’s breast have advanced dramatically in recent years. Rather than what previously was considered a radical mastectomy, we are now often able to remove the entire breast through small incisions with hidden scars that allow a woman to save her nipple and areola through a procedure called a “nipple-sparing mastectomy.” Following the breast and cancer removal, a plastic surgeon can rebuild the breast with an implant or one’s own extra tissue (fat from the abdomen or tummy tuck tissue).3 At this point in my explanation is often when I get asked the question about insurance coverage. The Women’s Health and Cancer Rights Act (WHCRA) of 1998 WHCRA requires insurance companies to cover reconstruction of the breast, as well as the opposite breast (to create symmetry), after a mastectomy.4 The law goes further to require coverage if you have other medical conditions such as a high risk gene even if you don’t have cancer yet. WHCRA requires coverage for the following:
There are few exceptions to this law for some types of government and church insurances, but in general, most women who need to have a mastectomy also have insurance coverage for reconstruction of their breasts. It is important to confirm specific details with your health insurer. In this era of climbing health care costs and an emphasis on value-based care,5 where “value” is defined as quality divided by cost, the quality of the care that a patient receives must include the sum total of that experience. Most surgeons can measure quality by how many surgical complications they may have or how often a cancer comes back. I would argue that how a woman feels about her body after removing her breast through an operation is one of the most important after-surgery quality measures we need to define. The day may come soon where limited health care dollars will limit coverage to only “medically necessary” services. Though less tangible and much harder to measure, this feeling of wholeness after surgery is well worth the investment, protected for now by the WHCRA. Author Bio:Sharon Lum, MD Dr. Lum is a Professor and Vice Chair of Academic Affairs of the Department of Surgery for the Loma Linda University School of Medicine. She serves on the Quality Integration Committee for the Commission on Cancer for the American College of Surgeons. Her research interests include quality measures and disparities in breast and other cancer outcomes and incorporation of patient reported outcomes in clinical decision-making for patients with breast diseases. References
Categories:Hereditary Cancer and Genetic TestingClose Hereditary CancerLearn about gene changes called mutations, how inherited mutations can lead to cancer, what types of cancer may be hereditary and how parents can pass gene mutations to their children. What is Genetic Testing?Explore information about genetic testing for an inherited mutation, the benefits and limitations of genetic testing and the type of results you might receive. How to Get Genetic TestingReview expert guidelines regarding who should consider genetic testing, how to find a genetics expert and how to move forward with testing. Hereditary Cancer Genes and RiskRead about different genes that are linked to hereditary cancer and the risks associated with inherited mutations in these genes. After Testing, Now What?Learn how to make medical decisions and assemble your health care team once you receive your genetic test results. Sharing with FamilyDiscover steps that will help you prepare to communicate your family medical history or genetic test results with relatives. Risk Management and TreatmentClose Screening and Risk ReductionReview national guidelines for cancer screening and prevention; this information is listed by gene mutation and by cancer type. Cancer TreatmentRead about cancer treatment options listed by gene mutation, type of cancer and type of treatment. MenopauseLearn about symptoms and options for managing early menopause caused by cancer treatment or preventive surgery. Wellbeing and SurvivorshipDiscover how cancer treatment and prevention affects long-term health, quality of life and emotional well-being; explore options for addressing these issues. Fertility and Family PlanningUnderstand the effects of cancer treatment and prevention on fertility and family planning, how pregnancy impacts hereditary cancer risk and options for assisted reproduction. Research and Clinical TrialsClose Why Enroll in Research?Learn why you should consider enrolling in a research study and your rights and protections as a research participant. How to Find StudiesThese tips and resources will help you locate clinical trials and studies enrolling people like you. Search and EnrollReady to enroll? Our tools will help match you to hereditary cancer detection, prevention and treatment studies. Help Shape ResearchFORCE trains patients who are new to science to use their personal experiences to help guide hereditary cancer research. Research CollaborationsLearn about ongoing studies, and the role that FORCE, our research advocates, and our partners have played in shaping the research.
Privacy, Policy and Legal IssuesClose Laws and ProtectionsLearn about key laws and legal protections that impact people with, or at increased risk of, hereditary cancer; and, how to file a grievance or complaint. Public Policy PrioritiesSee what legislative and regulatory policy issues FORCE is actively engaged in, representing the unique needs of people and families affected by hereditary cancer. Advocacy ArchiveRead about the public policy initiatives that FORCE undertook in the past, ensuring that the voice of the hereditary cancer community was heard. Advocacy DayAdvocacy Day brings the community together to educate Members of Congress about important issues faced by people with or at increased risk of hereditary cancers. Personalized GuidanceGet matched with a Peer Navigator volunteer who shares a similar experience as you for confidential 1:1 phone/email support and receive a free expert-reviewed resource guide. Support Meetings and EventsAttend support meetings or learn from experts at webinars and conferences. You can ask questions, share your story or just listen. Message BoardsOur message boards are available 24/7 and are the easiest way to reach out to others who are facing hereditary cancer. Private Facebook GroupIn this group, you can connect with others who are affected by hereditary cancer. Let’s unite and support each other. HelplinePeer volunteers return calls within 48 hours and provide nonjudgmental support and resources in English and Spanish. A Genetic Counselor helpline is also available. Insurance and Paying for CareFind information on insurance coverage and financial assistance for genetic services, risk management and cancer treatment. VolunteerFORCE has opportunities for people of our community to get involved in significant ways to raise awareness, provide support or help promote research of hereditary cancer. Behind the Headlines (XRAY)Our XRAY program takes you behind the headlines to bring you reliable information about cancer research-related news and information. ConferenceJoining FORCEs Against Hereditary Cancer is a virtual conference designed to empower individuals and families facing hereditary cancer. WebinarsOur live and on demand webinars feature presentations by experts on topics of interest and importance to our community. BlogOur blogs feature personal perspectives and deep dives into topics of interest to the hereditary cancer community. BrochuresOrder or download our educational materials. GlossaryFind definitions for commonly used terms. Sign Up for FORCE Newsletters FORCE advocates for families facing hereditary hereditary cancer in areas such as access to care, research, funding, insurance and privacy. Breast reconstruction coverage detailsThe Women’s Health and Cancer Rights Act (WHRCA) requires most group health insurers
Breast reconstruction surgery may be done at the same time as a mastectomy or at a later time. Insurance coverage cannot be denied based on the period of time between the mastectomy and the request for reconstructive surgery. Similarly, breast reconstruction or revisions cannot be denied because you had a different insurance plan at the time of the mastectomy; or because the mastectomy was not due to a cancer diagnosis. Despite the title, nothing in the WHCRA limits the benefit to patients with cancer. Many insurers will cover mastopexy or breast reduction and lift to preserve the viability of the nipple in preparation for a nipple-sparing mastectomy. While most health insurers will cover breast implant removal and replacement if complications occur in a patient who had a mastectomy and breast reconstruction. It's important to note that many breast implant manufacturers have warranties on their products which will cover replacement of a ruptured implant (and possibly the implant on the opposite side) plus financial assistance toward related surgical fees. WHRCA does not require 100% coverage by health insurance so copays, coinsurance and deductibles may apply. Some group health insurers limit coverage to in-network providers or use a less-favorable reimbursement formula for out-of-network providers. Medicare & MedicaidMedicare and Medicaid are public programs that are not bound by the WHRCA. They have their own rules. Medicare covers breast reconstruction after a "medically necessary" mastectomy typically associated with a cancer diagnosis, while Medicaid coverage varies by state. See the Insurance & Paying for Care section of our website for more information. Paying For Care
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How long after lumpectomy can you have reconstructive surgery?Most plastic surgeons recommend that you wait at least 6 months to 1 year after lumpectomy before having any surgical reconstruction. This allows your tissues to heal and allows any distortion or asymmetry to stabilize.
Can you have breast reconstruction after lumpectomy?Lumpectomy reconstruction or partial breast reconstruction, also known as oncoplastic reconstruction, is an option for patients who have had a lumpectomy and wish to recreate symmetry between the remaining breast and the other side.
Does a lumpectomy require reconstructive surgery?Many women who undergo a lumpectomy choose not to have reconstruction. Sometimes this is because the amount of tissue removed is small enough that it doesn't affect their breasts too much. But in many cases, women don't realize that there are options for reconstruction.
How long after radiation can you have breast reconstruction?It can be done 3–4 weeks after chemotherapy and 4–6 weeks after radiation therapy. This delay allows your body to heal properly so that there are fewer problems, or complications, with the breast reconstruction surgery.
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Does insurance cover breast reconstruction after lumpectomy
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