Yes, insurance generally covers breast reconstruction following a lumpectomy. Breast reconstruction involves restoring the breast’s shape and achieving symmetry after the removal of cancerous tissue. This coverage is mandated by federal law.
The Federal Law Mandating Coverage
The Women’s Health and Cancer Rights Act (WHRCA), a federal law passed in 1998, mandates that any health plan covering a mastectomy must also cover all stages of reconstruction. WHRCA applies broadly to most commercial group health plans, including those sponsored by employers, as well as to individual health insurance policies. The law’s purpose is to prevent insurers from classifying reconstruction as purely cosmetic, which they had frequently done before the Act was passed.
While the law provides wide protection, some exceptions exist. Plans like Medicare and Medicaid, for instance, are not bound by WHRCA but have their own separate rules that typically cover breast reconstruction. Additionally, certain self-funded, non-federal government plans may have the ability to opt out of the WHCRA requirements, though they must notify participants if they do so.
Defining Medically Necessary Reconstructive Procedures
The scope of coverage under WHRCA extends beyond rebuilding the breast mound itself. The law requires coverage for all stages of reconstruction on the treated breast, including the use of breast implants, tissue expanders, tissue flap procedures, acellular dermal matrix products, or various flap surgeries.
Furthermore, the Act mandates coverage for surgery on the opposite, untreated breast when necessary to achieve a symmetrical appearance. This means procedures like a reduction, lift (mastopexy), or augmentation on the healthy breast are covered to ensure balance. Achieving physical symmetry is recognized as an integral part of the overall reconstruction process.
Coverage also extends to reconstruction of the nipple and areola, including specialized tattooing procedures used to restore the natural appearance of the complex. The law also covers the provision of external breast prostheses and the treatment of physical complications that arise from the lumpectomy or reconstruction, such as lymphedema. However, coverage generally ceases when the procedure shifts from restoration and symmetry to purely cosmetic enhancement that is unrelated to the cancer treatment.
Practical Steps for Securing Coverage
Even with a federal mandate, patients must navigate administrative steps to secure payment, beginning with pre-authorization or pre-certification. This step is mandatory for most plans, requiring the patient and the surgical team to obtain official approval from the insurer before the procedure takes place. Failure to complete this process can lead to a denial of coverage.
Patients should also prioritize using in-network surgeons and facilities to limit their financial responsibility. While the reconstruction is covered, standard plan costs, including deductibles, co-pays, and co-insurance, still apply and must be budgeted for. Using out-of-network providers can dramatically increase the patient’s share of the cost, even if the procedure itself is covered.
The surgeon’s office plays a large role in documenting the medical necessity of the procedure, which is crucial for obtaining authorization. This documentation must clearly link the proposed reconstruction to the prior lumpectomy and the goal of restoring form and achieving symmetry. If an initial claim is denied, patients have the right to an internal appeal with the insurance company, followed by an external review process.
When appealing a denial, patients should gather all relevant documentation, including the surgeon’s notes, the specific medical codes used for the procedure, and a detailed letter justifying the medical necessity of the reconstruction stages. Understanding the rights provided under WHRCA and advocating for the legally mandated coverage can be an effective strategy in overturning an unwarranted denial.