Does insurance cover reconstructive surgery after mastectomy

Q: Are implants covered by insurance after mastectomy?

The Womens Health and Cancer Rights Act (WHRCA) requires most group health insurers to cover of all stages of breast reconstruction following a mastectomy or lumpectomy including, but not limited to: Breast implants.

Cancer
Cancer Information for Women
Cancer Treatment
Health Topics

Table of Contents Show

It's easy to get the care you need.
It's easy to get the care you need.
The vast majority of breast cancer survivors are good candidates.
Breast reconstruction can improve your quality of life.
Prostheses can be cumbersome.
You don’t have to live with jagged, indented scars.
It’s OK to wait.
You can pick an option that fits your lifestyle.
It’s covered by insurance.
Reconstructive Surgery After Breast Cancer
Does insurance have to pay for reconstruction after mastectomy?
Are implants covered by insurance after mastectomy?
What qualifies for breast reconstruction?
How long after mastectomy can you have reconstructive surgery?

It's easy to get the care you need.

See a Premier Physician Network provider near you.

After fighting breast cancer and having a lumpectomy or mastectomy, the cost of breast reconstruction surgery should not have to top a woman’s list of concerns.

Thankfully, a law created almost two decades ago has helped remove the stress of paying for breast reconstruction by requiring insurance companies to pay for the surgery.

Breast reconstruction is a type of surgery for women who have had all or part of a breast removed. During the surgery, a plastic surgeon rebuilds the breast to its previous size and shape.

Plastic surgeon Todd Hicks, MD, however, worries that many women are still unaware that the law exists.

“The Women’s Health and Cancer Rights Act (WHCRA) remains one of the best kept ‘open’ secrets that too many women simply aren’t taking advantage of after enduring a lumpectomy or mastectomy,” saya Dr. Hicks.

The law – created in 1998 – requires that group health plans, insurance companies, and health maintenance organizations (HMOs) that offer mastectomy coverage must also provide coverage for some other services related to the mastectomy, the full removal of the breast.

Most women who have had a mastectomy can have breast reconstruction surgery. The surgery can help rebuild the breast’s natural shape, create a more balanced look when wearing a bra or swimsuit, and eliminate the need for external prosthesis, such as forms worm in the bra.

All stages of breast reconstruction after a mastectomy are covered under the law. If only one breast was affected by the mastectomy, surgery and reconstruction of the other breast also are covered by the law, if needed, to create a symmetrical appearance.

“One of the wonderful things about this law is that there really is no time limit regarding when the benefit is administered,” said Dr. Hicks, a Premier Physician Network’s physician. “This applies to women who have had a mastectomy years ago, but who now feel as if they are in a place – both emotionally and physically – to consider reconstruction.”

In many cases, he said, talking about reconstruction becomes easier for a woman the further she gets from her journey with cancer.

Often, it can be hard for doctors and breast cancer patients to discuss breast reconstruction in the early phases of care after diagnosis because the patient is focused on trying to beat the disease, according to a study released in the Journal of the American Medical Association Surgery.

Breast cancer support organizations advise women to discuss reconstruction options with their health care team, including oncologists, radiologists, and surgeons.

Breast reconstruction is a process that is personal for every woman and needs a plan tailored to fit each person’s needs and desires, Dr. Hicks says. It is also important that women not let misconceptions keep them from considering the surgery.

“Women may have misconceptions about reconstruction, such as a fear that surgery will skew the accuracy of future breast screenings,” Dr. Hicks says. “It’s our hope that women will seek the advice of a professional to help direct their decisions.”

It's easy to get the care you need.

See a Premier Physician Network provider near you.

Source: Todd Hicks, MD, Premier Plastic Surgeons; American Cancer Society

breast cancer
breast reconstruction
breast reconstruction surgery
Dr. Todd Hicks
insurance
lumpectomy
masectomy
Premier Health
Premier Plastic Surgeons
Women's Health and Cancer Rights Act

Plastic and Reconstructive Surgery

Featured Experts:

Whether it’s been 20 days or 20 years since your lumpectomy or mastectomy, you’re likely a candidate for reconstruction.

More than 70 percent of women who forgo reconstruction at the time of their breast surgery don’t know it’s an option, don’t have access to a plastic surgeon, or are focused and worried about managing their diagnosis, says Gedge Rosson, director of breast reconstruction at Johns Hopkins.

Rosson and his colleague Michele Manahan shed some light on what most people may not know about delayed breast reconstruction:

The vast majority of breast cancer survivors are good candidates.
While every patient is different and approaches to reconstruction may vary, nearly every breast cancer survivor who is interested in breast reconstruction is a candidate.
Schedule a consultation with a breast reconstruction surgeon to learn more.
Breast reconstruction can improve your quality of life.
“Some patients don't have the opportunity for or are not interested in reconstruction when they are first treated for breast cancer,” says Manahan. "We can still offer breast reconstruction at any point, and it often helps patients feel better about their overall experiences and what their bodies have had to face."
Leading studies that compared quality-of-life assessments for women before and after breast reconstruction, Rosson and Manahan found that reconstruction, whether immediate or delayed, can greatly improve a woman’s sense of wholeness and well-being.
Breast reconstruction can also alleviate pain and chest tightness associated with radiation treatment and, in some cases, improve nipple sensation.
Prostheses can be cumbersome.
Patients that opt for prostheses often find that they’re heavy and hard to fit with their clothing. Prostheses may also require regular replacement. Breast reconstruction can be a permanent solution to restoring your breasts to a more natural shape and size.
You don’t have to live with jagged, indented scars.
Innovations in breast reconstruction surgery over that last decade have greatly improved appearance, including reducing the number of indentations and appearance of scars.
Surgeons at The Johns Hopkins Hospital perform the most advanced muscle-saving flap, fat grafting and implant procedures.
Watch this animated video to learn more about delayed reconstruction using tissue from the abdomen.
It’s OK to wait.
In many cases, your reconstructed breast will look just as good whether you had reconstruction during your mastectomy or after.
“We really do believe it’s never too late,” says Manahan. “You can wait and put it off, and when you’re ready, we will have many good choices for you.”
Even if you were counseled against breast reconstruction at the time of your treatment, advances in reconstructive techniques may qualify you for the procedure. Schedule a consultation with a breast reconstruction surgeon to learn more.
You can pick an option that fits your lifestyle.
Your surgeon can work with you to create a customized treatment plan to suit your preferences. For example, you can choose between breaking up breast reconstruction into one longer surgery or several shorter and less invasive ones. You’ll also have the choice to have your breast reconstructed using your own tissue from your belly, thighs, buttocks or back. Additionally, you can select reconstruction using implants made of saline or silicone.
It’s covered by insurance.
Health care costs are often a primary concern for patients facing any surgical procedure. For breast reconstruction after breast cancer, it doesn’t have to be. Federal law requires that breast reconstruction, in addition to other post-mastectomy benefits, be covered by medical insurance.

Reconstructive Surgery After Breast Cancer

This type of surgery requires not just a skilled and experienced surgeon but also a team of doctors and nurses who treat breast cancer. Johns Hopkins plastic and reconstructive surgeons specialize in complex breast reconstruction procedures and have successfully completed reconstructions for hundreds of women, restoring their self-image after cancer treatment.

Does insurance have to pay for reconstruction after mastectomy?

The Federal law This federal law requires most group insurance plans that cover mastectomies to also cover breast reconstruction. It was signed into law on October 21, 1998. The United States Departments of Labor and Health and Human Services oversee this law.

Are implants covered by insurance after mastectomy?

The Women's Health and Cancer Rights Act (WHRCA) requires most group health insurers to cover of all stages of breast reconstruction following a mastectomy or lumpectomy including, but not limited to: Breast implants.

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.

How long after mastectomy can you have reconstructive surgery?

This means reconstruction might be done 6 to 12 months after mastectomy or lumpectomy. Reconstruction also can be done years later if desired. Some women aren't ready to have the surgery sooner, or they change their minds about their initial decision to “go flat” or wear a prosthesis.