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Does Insurance Cover Breast Reconstruction After Cancer

Get Help Understanding Insurance And Patient Financial Responsibility

Will Insurance Cover Breast Reconstruction After Implant Removal Due To Breast Cancer? | MBAS

Toni Conner is the contact person for patients of UPMC Western Maryland Plastic Surgery who have financial questions about their plastic or reconstructive surgical procedure. Her contact telephone number is 240-964-8931. While patients are responsible for understanding their insurance coverage, she can help to answer questions and provide additional resources for those who need to finance any part of their surgery.

Please note, the information provided throughout this site is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images, and video, on or available through this website is for general information purposes only. If you are experiencing relating symptoms, please visit your doctor or call 9-1-1 in an emergency.

Austin Plastic & Reconstructive Surgery

  • Known for natural-looking aesthetic results in breast reconstruction and cosmetic surgery.
  • Elected by peers for inclusion in Texas Monthly’s Texas Super Doctors®: Rising Stars listing.
  • Reconstructed over 6,000 patients, including more than 2,500 DIEP flap reconstructions.
  • 4.9-star average rating over hundreds of reviews for reconstructive and cosmetic surgery.

Does Insurance Cover Prosthetics Mastectomy Bras And Accessories

May 13, 2021 | Blog

Going through breast cancer can be an emotional experience. any women have to go through chemo and radiotherapy treatments and surgeries to remove part or all of their breasts.

If youve had to go through a mastectomy surgery, and you dont want to experience another invasive operation, such as breast reconstruction, you have other options, such as a breast form. However, many women are concerned over the potential out-of-pocket costs associated with buying breast forms and mastectomy products.

Many health insurance plans cover breast prostheses, as well as mastectomy bras and accessories.

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Personal Stories About Breast Reconstruction After Mastectomy

These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.

I kind of went into shock when my doctor told me I had breast cancer and would need to have my right breast removed. I started listening again when she described how I could have my breast reshaped. Knowing I could have this done right away before I even woke up from the mastectomy made the whole thing easier to deal with. I chose to have DIEP flap surgery, using tissue from my belly. I knew it would take awhile to heal and look like a breast, and I did have to have surgery on my left breast to help them match. But I am so glad I did it. It has helped me feel stronger after the trauma of cancer.

Claudia, age 42

When my doctor first mentioned that I could have my breast rebuilt after the mastectomy, I was kind of interested. I didn’t know they could do things like that, taking tissue from your back or belly. But the more I thought about it, the more it didn’t feel right for me. It seemed like a distraction when all I wanted to focus on was beating the cancer and getting back to my life. I talked to my husband about it, and he totally supported my decision. Maybe sometime down the road I might change my mind. But for now I use a prosthesis in my bra, and this works fine.

Patrice, age 51

Jewel, age 73

Kerry-Ann, age 45

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Does Insurance Cover Breast Reconstruction?

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Key Points To Remember

  • Breast reconstruction may involve many different decisions, including when to have the surgery and what type of reconstruction to have. Be sure to understand your options, how long it will take to recover, and what kind of follow-up you will need.
  • Most women are able to have breast reconstruction. But it may not be a good choice if you are obese, smoke, or have serious health problems, such as heart disease or diabetes. These conditions increase your risk of serious problems after surgery.
  • It is important to be realistic about how your new breast will look and feel. The surgeon can show you pictures of other women who had the surgery you are considering. You can also ask to talk to women who have had the surgery.
  • Making a decision about breast reconstruction can feel very stressful. But talking with your doctor or plastic surgeon will help you find your best options.
  • If you choose not to have reconstruction or to wait, you can use a bra insert to help your clothes fit better.

Medicaid Coverage For Breast Reconstruction Surgery

The WHCRA of 1998 does not include the federal Medicaid program. Medicaid provides health insurance coverage to individuals and families with low income and no access to other resources. Each state is free to decide whether it includes breast reconstructive surgery as a covered benefit. to go to the Medicaid website for West Virginia.

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Does Your Insurance Plan Include Breast Prostheses

Due to the Womens Health and Cancer Rights Act of 1998, many insurance plans throughout the US now cover the cost of a prosthesis. Many also cover a custom prosthesis however, in this instance, it must be considered a medical necessity for the insurance company to payout.

A list of insurance plans covering prosthetics includes United Healthcare, Cigna Healthcare, and Blue Cross Blue Shield. As well as these plans, Medicare, Medicaid, and many other commercial insurance companies cover silicone breast forms every two years, two to four mastectomy bras per year, and foam prostheses every six months.

If you need help regarding your insurance policy, A Fitting Experience Mastectomy Shoppe can help you with billing and other assistance you may need.

Who Will Perform My Reconstruction How Do I Select A Surgeon

Reconstruction After Breast Cancer

Breast reconstruction surgery is performed by a plastic surgeon. While your surgical oncologist is responsible for your mastectomy and treating your cancer, your plastic surgeon focuses on reconstructing your breast. If you decide to have immediate reconstruction, the plastic surgeon will need to coordinate with your oncologist to plan your surgery. Plastic surgeons are first trained as medical doctors. After medical school, they receive five to eight years of specialized training in plastic surgery. Plastic surgeons perform many complicated surgeries. They re-attach hands after accidents, reconstruct body parts for burn patients, and repair wounds. When selecting a surgeon, you should ask about their experience with and training around breast reconstruction procedures. You should make sure that your doctor is a “board certified” or “board eligible” plastic surgeon. Also, your surgeon should be willing to talk with you about both cosmetic and surgical issues. Remember that the surgeon works for you: you can choose to stop reconstruction at any point, from choosing no reconstruction to declining nipple reconstruction or tattooing.

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What Do You Need To Look Into While You Are Using The Insurance For The Breast Reconstruction Surgery

There could be enough number of problems that you will come across even when your breast reconstruction surgery is covered by the insurance. Some of the problems include you opting for a newer process of breast reconstruction, if you have to make a more balanced appearance, if you have to undergo a surgery to correct the entire reconstruction procedure you had gone through or if you want that the reconstruction surgery of yours should be performed by a plastic surgeon who is not included in the network of the insurance plan.

You need to communicate with the provider of your plan up front and be updated about what exactly your insurance covers so that you do not have pay anything later unexpectedly. The administrator in the office of your plastic surgeon will help you find out the exact amount that will be covered by the insurance plan. The state health insurance agency and its commissioner would help you further to include the breast reconstruction as a part of the insurance coverage.

Should My Reconstruction Be Immediate Or Delayed

You’ve talked with your doctor and decided to have your breast reconstructed. Should you have it done at the same time as the mastectomy or wait until later? All types of breast reconstruction can be done either at the same time the cancerous breast is removed or later–even years later. Your doctor may suggest that one option is better for you, depending on your body and your health. Advantages of Immediate Breast Reconstruction:

  • You wake up after cancer surgery with a new breast, or the beginnings of a new breast, already in place.
  • Most women feel better about seeing the results of the cancer surgery for the first time if they have had immediate reconstruction.
  • It saves time and effort, since you have two surgeries at the same time.

Disadvantages of Immediate Breast Reconstruction:

  • You must bear the strain and the possible problems of two surgeries at once.
  • There is no chance to adjust to the loss of the old breast before you get the new one.
  • You must deal emotionally with cancer and with reconstruction at the same time. Some women prefer to have the cancer treated first and to think about reconstruction afterwards.

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What Kinds Of Surgery Can Reduce The Risk Of Breast Cancer

Two kinds of surgery can be performed to reduce the risk of breast cancer in a woman who has never been diagnosed with breast cancer but is known to be at very high risk of the disease.

A woman can be at very high risk of developing breast cancer if she has a strong family history of breast and/or ovarian cancer, a deleterious mutation in the BRCA1 gene or the BRCA2 gene, or a high-penetrancemutation in one of several other genes associated with breast cancer risk, such as TP53 or PTEN.

The most common risk-reducing surgery is bilateral prophylactic mastectomy . Bilateral prophylactic mastectomy may involve complete removal of both breasts, including the nipples , or it may involve removal of as much breast tissue as possible while leaving the nipples intact . Subcutaneous mastectomies preserve the nipple and allow for more natural-looking breasts if a woman chooses to have breast reconstruction surgery afterward. However, total mastectomy provides the greatest breast cancer risk reduction because more breast tissue is removed in this procedure than in a subcutaneous mastectomy .

Even with total mastectomy, not all breast tissue that may be at risk of becoming cancerous in the future can be removed. The chest wall, which is not typically removed during a mastectomy, may contain some breast tissue, and breast tissue can sometimes be found in the armpit, above the collarbone, and as far down as the abdomenâand it is impossible for a surgeon to remove all of this tissue.

Does Your Insurance Plan Cover Prosthetic Care


As well as covering breast prostheses, many insurance companies, especially employer-sponsored health plans, provide coverage. This is due to the Affordable Care Act that was introduced in 2010. The act federally mandated that small group health insurance plans must cover EHBs and must include prosthetic devices in the category.

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The Choice To Rebuild Your Breasts After A Mastectomy Is Yours

Knowing your insurance rights can help with your decision.

Under state and federal law , if your insurance company covers mastectomies, it must also cover related services, including reconstructive surgery and breast prostheses or forms if you don’t select surgery. This is true even if the mastectomy is not due to a cancer diagnosis and even if your surgery is delayed. Coverage must include:

  • All stages of reconstruction of the breast on which the mastectomy has been performed.
  • Surgery and reconstruction of the other breast to produce a symmetrical or balanced appearance.
  • Any external prostheses that fit into your bra before or during the reconstruction.
  • Treatment of physical complications of all stages of the mastectomy, including lymphedema or fluid build-up in the arm or chest.
  • Any medically necessary hospitalization for treatment.

Your insurer must notify you of this coverage when you enroll and every year after.

What Should I Consider When Evaluating The Cost Of Breast Reconstruction

Choose your surgeon based on quality, training, and experiencenot cost.

At The Aesthetic Society, patient safety and your satisfaction come first. Members of The Aesthetic Society go beyond when it comes to education, certifications, credentials, and ethical standards so they can safely deliver results that are beyond your expectations. Learn more about how our members go beyond for you.

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Insurance Broker Janice Hendricks Agency Generally Breast Lift Is Not Covered By Health Insurance Unless It Is Medically Necessary Ie

Does health insurance cover breast lift. Breast lifts or mastopexies are considered medically necessary when a large amount of weight loss has resulted in overhanging breast skin that causes chronic infections, itching and rashes. Furthermore, you also need to deal with your health fund directly regarding funding contributions to determine if you are eligible with the level of cover you have. Breast reduction and health insurance.

In order to claim your breast lift surgery using your private insurance, you must be eligible for the medicare item number. Also, as an aside, breast lift, has never been a covered procedure with any insurance carrier unless it is to match a breast reconstruction for breast cancer. In most cases, the medical necessity of the procedure is what comes into play.

Appealing breast reduction results sometimes necessitate a breast lift of the remaining breast tissue and nipple. It is universally believed by patients that if a surgery is considered reconstructive, it is medically indicated and covered by health insurance. Patients can explore various financing options and pay for the procedure in affordable monthly installments.

Not too long ago breast reduction surgery was not covered by insurance at all. If the insurance company deems the procedure is medically necessary, they may cover it. More important than price is safety and experience.

How To Find An Insurance Plan That Covers Prosthetic Devices

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If you are about to undergo mastectomy surgery and your current insurance policy does not cover prosthetics, including breast forms, mastectomy bras, and accessories, but you want to find one that does, consult the health insurance marketplace.

Also referred to as the health insurance exchange, the marketplace is where you can buy a specific health insurance plan that is most suited to you and your family. Set up again by the ACA, the marketplace makes it easier to view available plans in your state or area and compare them to other policies before making the purchase that is right for you.

With the help of marketplace health insurance, many people who did not realize they were eligible for coverage for prosthetic devices and even mastectomy bras and accessories can easily access plans that can help them financially and mentally.

Once youve found your perfect policy that covers prosthesis and mastectomy bras, explore mastectomy bras and breast forms in a range of styles and sizes to suit your needs.

The Amoena Balance Adapt Air Special Varia 234 Adjustable Breast Shaper comes in a variety of sizes and is completely adaptable to fit the needs of any woman.

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Does Insurance Pay For Breast Reconstruction After Mastectomy

Jun 21, 2021 | Reconstruction

There are many factors to consider before having breast reconstruction, including cost and payment after surgery. Well, did you know that there are safeguards in place that allow you to have this procedure covered by your insurance?

A central reason that insurance companies are required to pay for breast reconstruction is the Womens Health and Cancer Rights Act of 1998 . This federal law protects a womans right to have reconstruction after mastectomy due to medical reasons. This includes women who have had breast cancer, as well as those who have prophylactic mastectomies because of risk factors like a strong family history of breast cancer or gene mutations .

Generally, insurance companies must cover breast reconstruction if they also cover mastectomy. This applies to group health plans, individual insurance plans, and plans with Health Maintenance Organizations . However, certain church or government plans are possible exceptions to this, so its important to check with your plan administrator about your mastectomy and reconstruction benefits if you have these kinds of insurance plans.

Beyond just initial reconstructive surgery, there are additional medical and surgical treatments for which insurance plans must provide benefits. These surgical benefits include all stages of reconstruction of the breast removed during mastectomy, as well as surgery and reconstruction for the other natural breast for symmetry and appearance.

The Womens Health And Cancer Rights Act

In 1998, the United States Department of Labor and Health and Human Services enacted the Womens Health and Cancer Rights Act . The mandates of WHCRA apply to all group health plans that went into effect after October 1, 1998. It applies to Health Maintenance Organizations , private health insurance companies, and group health plans that offer benefits to cover a mastectomy.

The WHCRA further stipulates that all insurers offering mastectomy benefits provide coverage for the following:

  • Reconstruction of the breast that was surgically removed due to cancer.
  • Reconstruction and surgery of the remaining breast to create a balanced appearance.
  • The breast implant itself.
  • Treatment for any physical complications of the mastectomy.

Patients may have to pay a deductible or co-insurance for reconstructive surgery, but it must be the same that they would pay for any other type of medical procedure.

The Department of Labor and Health and Human Services will impose sanctions against any insurance provider that changes eligibility requirements in order to drop the patient. It also does not tolerate insurers making a lesser payment to medical providers for completing reconstructive surgery or offering them an incentive to refuse to do the surgery.

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