Insurance Coverage for Breast Reconstruction

The Women's Health and Cancer Rights Act of 1998 (WHCRA)

Signed into law on October 21, 1998, the Women's Health and Cancer Rights Act (WHCRA) is a federal law that requires group health plans, insurance companies, and health maintenance organizations (HMOs) that provide coverage for mastectomies to also provide coverage for reconstructive breast surgery and prostheses following the mastectomy. Patients insured under an individual plan are also protected by the WHCRA. The WHCRA is not limited to cancer patients; it also protects patients who undergo a mastectomy due to other medical reasons.

How Does the WHCRA Protect You?

If the WHCRA applies to you, and you choose to undergo breast reconstruction, insurance coverage must be provided for:

• All stages of reconstruction of the removed breast or breasts.
• Surgery and reconstruction of an untreated breast to create a symmetrical appearance.
• Prostheses, or breast implants.
• Treatment of any physical complications occurring at any stage of the mastectomy, including lymphedema.

The WHCRA also requires that insurance companies provide you with a notice of coverage at the time you enroll in the plan, as well as every year you have the plan. This notice serves to inform you of the four categories of coverage required under the WHCRA, as well as information on how you can obtain more detailed information on mastectomy-related benefits available under your plan.

Exceptions and Restrictions

Although most group health plans and insurance companies that cover mastectomy are required by law to provide coverage for breast reconstruction, some exclusions and restrictions may apply:

• Coverage provided by a "church plan" or "governmental plan" may not be subject to this law.
• Insurance companies are not required to cover minimum hospital stays in connection with a mastectomy.
• Coverage for preventive services related to the detection of breast cancer are not required.
• The WHCRA does not require group health plans or insurance companies to cover mastectomies.

It is also important to note that some surgeons may use breast reconstruction techniques that your insurance policy does not cover. For example, flap reconstruction - the use of the patient's own tissue to reconstruct the breast mound - is costlier than reconstruction using implants, but it has a higher success rate. If you choose to undergo a breast reconstruction procedure your policy does not cover, you may have to pay for at least a portion of the procedure out of pocket. Anyone who requires or has undergone a mastectomy should speak with their insurance plan administrator about which breast reconstruction procedures their policy will cover.  

Communication and Persistence

Insurance companies are in the business of helping to meet your medical needs. Therefore, it is imperative that your surgeon's office presents thorough justification for the projected scope of your procedure. Sometimes the phrasing used to describe this scope can make the difference between approval and denial. It is important that your surgeon's office uses terms specified in the ICD-10 code, the standard system of classification used by all insurance plans.

Even after presenting a meticulously planned treatment scope, there is no guarantee that the insurance company will approve coverage. Persistence is the key - you and your doctor can work together to revise the description to justify the projected scope of treatment in the eyes of the insurance company. Sometimes this can include using photos of the treatment area (excluding your face) to illustrate why the care you request is necessary.

If you have questions about insurance coverage for breast reconstruction, Dr. Oren Lerman's compassionate and knowledgeable staff in Manhattan, NY, can provide answers. If you are interested in undergoing breast reconstruction by Dr. Lerman, his staff can speak to your insurance provider on your behalf to present thorough justification for a projected treatment scope, and to determine what your provider will contribute to the cost of his care.  Financing options that can place out-of-pocket expenses comfortably within your budget can also be discussed with Dr. Lerman's staff. To learn more, please contact us today.

Insurance policies can be complicated, but you can rely on the fact that if your provider covers mastectomy, they are most likely obligated to cover breast reconstruction.

Nine Questions To Ask Your Insurance Provider

Insurance policies can be complicated, but you can rely on the fact that if your provider covers mastectomy, they are most likely obligated to cover breast reconstruction. However, the process of choosing a surgeon and securing coverage can involve many specific requirements set forth by your provider. When speaking with your insurance company, there are several questions you should ask:

1. How many consultations will you cover? In other words, how many surgeons will your insurance company pay for you to meet in order to select the right one for your surgery?
2. How much is my deductible and co-pay?
3. Can I choose a surgeon outside my network?
4. Is my coverage limited only to specific breast reconstruction techniques?
5. If I choose a surgeon outside my network, or choose to undergo surgery incorporating techniques not within the scope of my coverage, how much will insurance contribute to the cost of my care?
6. Is there a limit on the amount of coverage you will provide for my breast reconstruction?
7. If my breast reconstruction requires other specialists in addition to my surgeon, will you cover their fees?
8. Do you cover the expense of a hospital stay?
9. Is there a limit to the amount of hospital stay you will cover?

Contact Us

Expertly performed breast reconstruction can provide substantial benefits, and if your insurance company covered your mastectomy, you likely also have a right to coverage of breast reconstruction. If you are in need of a mastectomy, or if you have already undergone the procedure and are exploring breast reconstruction options, Dr. Lerman is a leader in his field who can use the latest techniques to restore your breasts. If you would like to schedule a consultation, please contact us today.