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Is breast reconstruction surgery covered by insurance?

Erik A. Hoy, MD
Plastic Surgery
Since 1998, Congress has mandated universal insurance coverage for breast reconstruction after removal of breast cancer.  This even includes staged procedures such as the filling of adjustable breast implants or reconstruction of the nipple.  It also covers cases in which a breast lift is required in a normal breast in order to better match a reconstruction on the cancerous breast.  Now, new legislation in New York state will require doctors and healthcare centers to review reconstruction options with patients prior to the resection of their breast cancer.  If the initial center does not perform reconstructions, the patient must be referred to one that does.  These laws help protect a patient's access to reconstructive surgery after breast cancer removal.

Stuart A. Linder, MD
Plastic Surgery
Both federal and state laws require that breast cancer reconstruction be covered by health insurance.  This may include not only the affected breast but the contralateral breast in order to regain a form of symmetry.  In general, breast cancer reconstructions may require multiple stages and each of these stages should be covered by your insurance.  Stages can include tissue expanders, breast implant placement status post expansion, autologous tissue transfer, and nipple-areolar reconstruction.
The Women's Health and Cancer Rights Act (WHCRA) of 1998 does include requirements for insurance companies to cover reconstruction of a breast defect following a mastectomy.  It also provides for reasonable correction of asymmetry.  The caveat, however, is that the act exempts government plans from this requirement (such as Medicare and Medicaid).  My personal experience, however, is that Medicare is quite cooperative in assisting women with reconstruction following mastectomy despite not being legally bound to such.
Mark Sisco, MD
Plastic Surgery
Federal law has mandated that insurance companies cover patients undergoing reconstruction breast cancer surgery or risk reducing breast surgery. Learn more from Dr. Mark Sisco on behalf of NorthShore University about breast reconstruction surgery.
Ajay K. Sahajpal, MD
Transplant Surgery
It generally isn't covered for purely cosmetic purposes, unless part of a cancer operation to remove the breast and reconstruct.
Heather L. Karu, MD
Plastic Surgery
If breast reconstruction surgery is needed to restore symmetry after a partial or full mastectomy, can you really call the procedure merely cosmetic? In this video, Dr. Heather Karu discusses a patient's legal rights when it comes to reconstructive surgery.

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.