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:
- All stages of reconstruction of the breast on which the mastectomy was performed
- Surgery and reconstruction of the other breast to produce a symmetrical appearance
- Prostheses
- Treatment of physical complications of the mastectomy, including lymphedema
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
- //www.cancer.org/cancer/breast-cancer/treatment/surgery-for-breast-cancer.html
- Hart AM, Pinell-White X, Losken A. The Psychosexual Impact of Postmastectomy Breast Reconstruction. Ann Plast Surg. 2016;77(5):517–522
- //www.cancer.gov/types/breast/reconstruction-fact-sheet
- //www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/publications/your-rights-after-a-mastectomy.pdf
- //catalyst.nejm.org/doi/full/10.1056/CAT.17.0558
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Breast reconstruction coverage details
The Women’s Health and Cancer Rights Act (WHRCA) requires most group health insurers
- Breast implants
- Acellular dermal matrix products
- Flap reconstruction
- Nipple/areolar reconstruction and tattooing
- Surgery for symmetry of the contralateral (opposite) breast
- Revision of previously reconstructed breast
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 & Medicaid
Medicare 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
- Alliance in Reconstructive Surgery (AiRS) Foundation provides grants to offset the costs of breast reconstructive surgery for women in need.
- My Hope Chest helps fund reconstruction for breast cancer survivors under the age of 65.
- Patient Advocate Foundation provides case managers who help identify financial assistance programs and resources for those facing challenges.
- If your insurance company denies coverage of mastectomy or breast reconstruction, visit the Health Insurance Appeals section of our website for guidance and resources.
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