When you have breast cancer, your first concern is doing whatever is necessary to survive the disease. This can include the removal of one or both of your breasts. Some women are fine with having no breasts after surgery while others want to undergo reconstructive surgery as soon as possible. There is no right or wrong answer, only what feels like the best decision for you. One thing that can make a difficult decision even more challenging is concerns
about whether insurance will cover the cost of breast reconstruction surgery. The federal government mandates that your insurance provider pay for the costs under certain circumstances. The Cecil B. Highland, Jr. and Barbara B. Highland Cancer Center at UHC encourage you to learn whether this applies to your current situation. The Women’s Health and Cancer Rights Act (WHCRA) was introduced by the Department of Labor
and Health and Human Services in 1998 and passed by Congress the same year. Insurers that offer benefits for reconstructive surgery after a mastectomy must follow the mandates of WHRCA if the plan went into effect after October 1, 1998. This includes group health plans, health maintenance organizations (HMO), preferred provider organizations (PPO), and private insurers. WHCRA also describes what insurance companies that offer benefits for a mastectomy must cover. This includes: If an insurance plan requires payment of a deductible or a percentage of the expenses for breast reconstructive surgery, it cannot be higher than it would be for other surgical procedures. Additionally, an insurer cannot change its eligibility
requirements to deny coverage for surgery, offer incentives to surgeons to refuse the surgery, or pay a provider less for completing the surgery. Any of these actions could result in fines and other sanctions from the federal government. The WHCRA of 1998 does not include the federal Medicaid program. Medicaid provides health insurance coverage to individuals and families with low income and no access to other resources. Each
state is free to decide whether it includes breast reconstructive surgery as a covered benefit. Click here to go to the Medicaid website for West Virginia. Breast Reconstruction Surgery and the Medicare ProgramWhile Medicaid is an income-based program, Medicare is a program covering all people age 65 and older as well as some younger people with a permanent disability. One of the biggest complaints that Medicare users have about the program is that it can be complicated and difficult to understand. If you have Medicare, we encourage you to learn about your benefits at the start of your breast cancer treatment. Breast prostheses worn after a mastectomy is covered by Medicare Part B. This is the portion of the program that offers medical insurance. Specialty bras are included in the category of breast prosthesis. Medicare Part B also covers your costs, less any deductible or co-insurance, if you have breast reconstruction surgery performed at an outpatient center. Medicare Part A kicks in for patients who are admitted to a hospital for breast reconstruction surgery. Medicare requires a 20 percent co-payment for each breast prosthesis in addition to the physician’s fee. You can learn more about each part of Medicare at this page. Reach Out to Your Cancer Patient Navigators with Additional QuestionsWe understand that insurance can be complex in the best of circumstances. When you’re dealing with the surgical removal of your breasts and reconstructive surgery, it can be downright overwhelming. Your cancer patient navigators are here to help. While they cannot make coverage decisions, they can help you understand your insurance benefits and provide referrals to additional resources if necessary. Please note, the information provided throughout this site is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images, and video, on or available through this website is for general information purposes only. If you are experiencing related symptoms, please visit your doctor or call 9-1-1 in an emergency.  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: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.
Is reconstruction necessary after lumpectomy?Is reconstruction necessary after lumpectomy? Reconstruction is not always necessary after lumpectomy. But you should ask your breast surgeon if this is something to consider. If possible, it's best to perform reconstruction at the same time as the lumpectomy (I'll explain why in a minute).
Is breast reconstruction covered by medical?WHCRA requires insurance companies to cover reconstruction of the breast, as well as the opposite breast (to create symmetry), after a mastectomy. 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.
What qualifies for breast reconstruction?You may be a candidate for breast reconstruction if: You are able to cope well with your diagnosis and treatment. You do not have additional medical conditions or other illnesses that may impair healing. You have a positive outlook and realistic goals for restoring your breast and body image.
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Does insurance cover reconstructive surgery after lumpectomy
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