DIEP Flap surgery is a specialized form of breast reconstruction that uses a patient’s own abdominal tissue to rebuild the breast after a mastectomy. This technique, which stands for Deep Inferior Epigastric Perforator, is considered muscle-sparing because it preserves the abdominal wall muscle, unlike older flap procedures. DIEP Flap is often preferred for its potential to offer more natural results, a faster recovery, and a reduced risk of long-term core strength issues. While the procedure is medically complex and costly, its coverage, like all forms of breast reconstruction, is largely mandated by federal law, though the specifics depend on the individual’s health insurance policy.
The Legal Obligation to Cover Reconstruction
The question of insurance coverage for breast reconstruction is primarily answered by federal legislation called the Women’s Health and Cancer Rights Act (WHCRA) of 1998. This act stipulates that if a group health plan or health insurance issuer covers a mastectomy, it must also cover all stages of breast reconstruction following that procedure. The mandate covers reconstruction of the breast where the mastectomy was performed, and surgery on the other breast to achieve a symmetrical appearance.
WHCRA’s scope includes post-mastectomy care, such as prostheses and the treatment of physical complications like lymphedema. Since DIEP Flap surgery is a recognized, medically accepted method of breast reconstruction, it falls under this legal obligation for coverage. The law ensures that patient choice, guided by a medical provider’s assessment, is protected when selecting the most appropriate reconstructive method.
The coverage required by WHCRA is comprehensive. This includes the necessary hospital stays, operating room fees, and the professional fees for the surgical team and anesthesiologists. This federal protection applies to most group health plans and individual health insurance policies, including self-funded plans. Public programs like Medicare and Medicaid operate under their own sets of rules, though they generally cover medically necessary reconstruction as well.
Getting Approval and Navigating Plan Specifics
Although the law mandates coverage for breast reconstruction, it does not remove the administrative requirements imposed by insurers. The first step toward securing coverage is obtaining pre-authorization, or prior approval, from the insurance company before the surgery is scheduled. This process requires the surgeon’s office to submit procedure codes and documentation to demonstrate that the DIEP Flap is “medically necessary” for the patient.
A challenge arises when dealing with network access, particularly for a specialized procedure like DIEP Flap, which few surgeons perform. While WHCRA mandates coverage, it does not require a health plan to have a specific provider in its network. If a qualified DIEP Flap surgeon is out-of-network, the patient may face higher out-of-pocket costs, even if the procedure itself is covered. If the insurer cannot provide an in-network surgeon with the necessary expertise, the patient’s team may request a “GAP exception” to have the out-of-network provider reimbursed at the in-network rate.
Patients must consider their financial responsibility, which is defined by their specific plan’s cost-sharing structure. Even with full coverage, the patient remains responsible for their deductible, co-pays, and co-insurance until they reach their out-of-pocket maximum. Because DIEP Flap is a major, multi-stage surgery, patients often meet their annual out-of-pocket limits quickly. The surgical team’s financial coordinator is the best resource for calculating these estimated patient responsibilities.
What to Do If Coverage is Initially Denied
If the insurance company initially denies the pre-authorization for a DIEP Flap, patients have formal steps they can take to challenge the decision. The first step is to request a written denial that clearly states the specific reason for the refusal. Understanding the exact rationale, such as a claim of “not medically necessary” or a coding issue, is the foundation for an effective appeal.
Patients should then initiate the internal appeals process, which is a formal review by the insurance company itself. This requires compiling all relevant documentation, including a letter of medical necessity from the surgeon, which argues why the DIEP Flap is the most appropriate option for the patient’s condition. The surgeon’s office, particularly the billing or patient advocacy staff, is instrumental in preparing this detailed submission.
If the internal appeal is unsuccessful, the patient has the right to pursue an external review. This involves an independent third party, often a state-regulated entity, reviewing the case and the insurer’s decision. The external review process removes the final decision-making authority from the insurance company and is often a successful route for overturning denials for medically necessary procedures. It is essential to act quickly, as strict deadlines apply to both internal and external appeal submissions.