Will Insurance Cover Breast Reconstruction?

By Julie Vasile, M.D. on January 22, 2014

Stamford Breast Reconstruction and InsuranceFollowing a mastectomy, many women wish to restore the breasts to a full and feminine form. However, with the debt of medical bills that many patients have as a result of cancer treatment, the last thing most patients want to do is spend more money. What many of Dr. Julie Vasile’s patients do not know is that breast reconstruction is almost always covered by insurance. Our staff is happy to help our patients understand their insurance benefits, so that they receive the breast reconstruction insurance coverage  benefits they are entitled to and achieve the feminine look they desire.

Women’s Health and Cancer Rights Act

In October of 1998, the Women’s Health and Cancer Rights Act (WHCRA) was signed into law. This federal law ensures that most insurance companies provide coverage for breast reconstruction. With the exception of certain church plans and government plans, this act requires that all group plans, insurance plans, and HMOs who provide coverage for mastectomies also provide coverage for reconstruction. The law specifies that coverage should include all of the following aspects of reconstruction:

  • Reconstruction of the breast that was removed via mastectomy
  • Reconstruction of the other breast in order to achieve symmetry between the two breasts
  • Any external prostheses that may be required before, during, or after the reconstruction process

In addition, under the WHCRA, the type of breast reconstruction procedure that is covered is not limited. Patients are free to explore reconstruction options and choose the technique that is best suited to their unique needs and desires. Insurers who provide coverage for breast reconstruction will offer coverage for any of the following breast reconstruction techniques:

  • DIEP flap reconstruction (in which tissue from the abdomen is used to create a breast)
  • GAP flap reconstruction (which uses tissue from the buttocks to construct a breast)
  • PAP flap reconstruction (the breast is constructed with tissue from the upper thigh)
  • TDAP flap reconstruction (the breast is constructed with tissue from the upper back)
  • Breast implant reconstruction (a breast implant is inserted after the skin has been stretched)

Will There Be Out-of-Pocket Costs?

It is possible for patients to have out-of-pocket expenses for breast reconstruction. However, in order to protect patients’ rights, the insurance provider can only charge co-pays that are similar to those that are charged to other covered procedures. So if an insurance provider covers 80 percent of the cost of other procedures, the amount of coverage for breast reconstruction should also be 80 percent. With the insurance coverage that is required via the WHCRA, most women find that if there is any out-of-pocket expense, the final patient cost for breast reconstruction is still manageable.

Schedule a Consultation

Dr. Julie Vasile and her staff are happy to help patients communicate with their insurance providers to determine coverage for breast reconstruction. We believe that all women deserve to achieve the natural breasts they desire following a mastectomy. If you have questions about any of the many options available for breast reconstruction, schedule a consultation with Dr. Vasile at your earliest convenience. We look forward to hearing from you!

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