Is breast reconstruction surgery covered by insurance?
The state and the federal laws demand the breast reconstructive surgeries are covered by the insurance. The insurance may not cover the affected breast, but the contralateral breast in order to gain symmetry again.
Does Medicare or Medicaid cover breast reduction surgery?
Original Medicare benefits do not usually cover cosmetic or elective surgeries. Eligibility for Medicare coverage of breast reduction surgery requires that you have been experiencing symptoms for at least six months, and you must have previously tried other non-surgical means of medical intervention that have failed for symptom relief.
Will my insurance cover my breast reduction?
Well, the good news is most medical insurance policies cover breast reduction surgery. However, this depends on a case to cases basis. The only way to find out if your procedure is under coverage is to call your insurance carrier. Insurance policies are unique to individuals, so yours may differ from your friend’s, sister’s, or mother’s.
How much does it cost for breast reconstruction surgery?
The average cost of breast reconstruction surgery is $15,200, according to 3,871 reviews from RealSelf members, but complex cases can cost as much as $37,000 without health insurance coverage. Read on to find out why you might pay more or less for breast reconstruction, when insurance covers it, and whether the cost is really worth it.
Can breast reconstruction be covered by insurance?
The Federal law This federal law requires most group insurance plans that cover mastectomies to also cover breast reconstruction. It was signed into law on October 21, 1998. The United States Departments of Labor and Health and Human Services oversee this law.
What qualifies for breast reconstruction?
You may be a candidate for breast reconstruction if: You are able to cope well with your diagnosis and treatment. You do not have additional medical conditions or other illnesses that may impair healing. You have a positive outlook and realistic goals for restoring your breast and body image.
Does insurance cover a mastectomy?
Insurance companies are mandated by federal law to cover patients' procedure of choice in all cases of cancer patients who have had mastectomies, as well as surgery on the opposite breast to achieve symmetry.
Can belly fat be used for breast reconstruction?
An abdominal wall flap procedure uses tissues from the tummy. Most times the tummy provides enough tissue for breast reconstruction, so no breast implants are needed. The tummy flap names are based on how the tissue is transferred and if the abdominal wall muscle is used or not.
How painful is breast reconstruction surgery?
Right after the surgery, you will probably feel weak, and you may feel pain for 2 to 3 weeks. You may have a pulling or stretching feeling in your breast area. You can expect to feel better and stronger each day, although you may need pain medicine for a week or two.
What is the recovery time for breast reconstruction?
Most women can start to get back to normal activities within 6 to 8 weeks. If implants are used without flaps, your recovery time may be shorter. Some things to keep in mind: Certain types of reconstruction surgery do not restore normal feeling to your breast, but in other types some feeling might return over time.
What can go wrong with breast reconstruction?
The possible risks of breast reconstruction include, but are not limited to, bleeding, infection, poor healing of incisions and anesthesia risks. You should also know that: Flap surgery includes the risk of partial or complete loss of the flap and a loss of sensation at both the donor and reconstruction site.
How long do you have to take off work for a mastectomy?
It's not uncommon to take several weeks off from work while recovering from surgery — both physically and emotionally. The amount of time taken varies from person to person, but usually this ranges between 4 and 8 weeks. When you return to work can also depend on the type of work you do.
What is the best reconstruction after mastectomy?
Inserting a breast implant is the least invasive breast reconstruction procedure. It may not require extra time in the hospital if it can be done at the same time as the mastectomy. For this reason, implants are better for women with small or medium-sized breasts with little or no sagging [179].
Why can't you keep your nipples after a mastectomy?
A: Yes, the procedure is generally safe, with the usual risks of having surgery. The specific risks of having nipple-sparing mastectomy include the fact that because we remove all of the tissue behind the nipple — in what we call the nipple core — there can be an interruption of the blood supply to it.
Does fat transfer last in breasts?
Does Fat Transfer Last? Yes. When performed correctly, the use of body fat as an augmentation material for the breasts is highly effective and long-lasting.
Where do they take skin from for breast reconstruction?
Flaps used for breast reconstruction most often come from the abdomen or back. However, they can also be taken from the thigh or buttocks. Depending on their source, flaps can be pedicled or free. With a pedicled flap, the tissue and attached blood vessels are moved together through the body to the breast area.
How many surgeries are required for breast reconstruction?
It is well recognized that breast reconstruction is a multistage process,10 which was confirmed in our study where the mean number of the total operations was greater than 2. This finding reflects the complexity of breast reconstruction compared with other breast surgeries.
Will I need reconstruction after lumpectomy?
Although not always necessary, oncoplastic or partial breast reconstruction at the time of lumpectomy can be considered before surgery. Some patients are better off waiting until after their cancer treatment is complete while others will benefit from immediate reconstruction done in conjunction with a plastic surgeon.
What are the types of reconstruction?
IMMEDIATE RECONSTRUCTION.DELAYED RECONSTRUCTION.BILATERAL RECONSTRUCTION.IMPLANT BASED RECONSTRUCTION.Other.
Can you have reconstructive surgery at the same time as mastectomy?
Reconstructive surgery can be performed at the same time as your mastectomy surgery. This procedure is called immediate reconstruction. Immediate reconstruction offers the benefit of eliminating at least one surgery. It may allow you to get back to life as usual more quickly.
What insurance covers mastectomy?
WHCRA also describes what insurance companies that offer benefits for a mastectomy must cover. This includes: 1 Breast implants 2 Breast reconstruction if it was removed to prevent the spread of cancer 3 Reconstructive surgery of the intact breast to create a symmetrical appearance 4 Treatment to address mastectomy complications, if any
Can breast reconstruction surgery be denied by insurance?
If an insurance plan requires payment of a deductible or a percentage of the expenses for breast reconstructive surgery, it cannot be higher than it would be for other surgical procedures. Additionally, an insurer cannot change its eligibility requirements to deny coverage for surgery, offer incentives to surgeons to refuse the surgery, or pay a provider less for completing the surgery. Any of these actions could result in fines and other sanctions from the federal government.
Is breast prosthesis covered by Medicare?
Breast prostheses worn after a mastectomy is covered by Medicare Part B. This is the portion of the program that offers medical insurance. Specialty bras are included in the category of breast prosthesis. Medicare Part B also covers your costs, less any deductible or co-insurance, if you have breast reconstruction surgery performed at an outpatient center. Medicare Part A kicks in for patients who are admitted to a hospital for breast reconstruction surgery.
When was the Women's Health and Cancer Rights Act passed?
The Women’s Health and Cancer Rights Act (WHCRA) was introduced by the Department of Labor and Health and Human Services in 1998 and passed by Congress the same year. Insurers that offer benefits for reconstructive surgery after a mastectomy must follow the mandates of WHRCA if the plan went into effect after October 1, 1998. This includes group health plans, health maintenance organizations (HMO), preferred provider organizations (PPO), and private insurers.
Is Medicare based on income?
While Medicaid is an income-based program, Medicare is a program covering all people age 65 and older as well as some younger people with a permanent disability. One of the biggest complaints that Medicare users have about the program is that it can be complicated and difficult to understand. If you have Medicare, we encourage you to learn about your benefits at the start of your breast cancer treatment.
What is WHCRA in medical terms?
WHCRA is also known as Janet's Law, named after Janet Franquet, who was denied reconstructive surgery after a mastectomy in 1997. Reconstruction of the breast on which the mastectomy was performed. Surgery and reconstruction of the other breast to create a symmetrical appearance. Prostheses (breast implants).
What is WHCRA insurance?
WHCRA applies to three types of health insurance coverage, according to the Department of Health and Human Services: Self-funded group plans. Fully insured group plans. Individual health insurance plans.
What is the law that covers breast reconstruction?
The Women's Health and Cancer Rights Act ( WHCRA) of 1998 is a federal law that that requires health insurance companies and self-insured group health plans that cover mastectomies to also provide benefits for mastectomy-related services, including breast reconstruction surgery. If you're receiving health insurance benefits in connection with a mastectomy and you elect breast reconstruction surgery, WHCRA states that the insurer also must cover:
Why was Janet Franquet denied breast reconstruction?
Her insurance company denied her breast reconstruction because it considered the surgery cosmetic rather than medically necessary.
How to find out if your group health insurance is fully insured?
To find out if your group health coverage is fully insured or self-insured, check your Summary Plan Description or contact your plan administrator at work. Also, keep in mind that some state laws provide more protections than WHCRA. To learn more, contact your state's insurance department. WHCRA requires insurance companies to notify plan members ...
Why did the insurance company deny her breast reconstruction?
Her insurance company denied her breast reconstruction because it considered the surgery cosmetic rather than medically necessary. During a lengthy appeals process, which Franquet eventually won, her doctor performed the surgery for free.
Does health insurance cover breast reconstruction?
State health insurance laws sometimes apply. Some states require the same coverage for breast reconstruction that is legislated by WHCRA and also mandate minimum hospital stays in connection with a mastectomy.
Is Breast Reconstruction Surgery Covered By Insurance?
If you are undergoing a breast reconstruction surgery procedure, it should be covered by the health insurance plan. The health insurance plan must help you carry out this surgery if you undergoing it soon after the lumpectomy or the mastectomy or few years later.
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.
What is the WHCRA?
Signed into law on October 21, 1998, the Women’s Health and Cancer Rights Act (WHCRA) helps protect many women with breast cancer who choose to have their breasts reconstructed after a mastectomy or lumpectomy. This federal law requires insurance plans that cover mastectomies or lumpectomies to also cover breast reconstruction.
Does WHCRA cover mastectomy?
The WHCRA therefore covers implant-based reconstruction as well as reconstruction using your body’s own tissue, regardless of whether these procedures are performed at the time of mastectomy and lumpectomy or at a later date. Dr. Potter works closely with you and your insurance company to make sure you receive the full medical benefits you are entitled to and deserve. Her patients travel from all over the United States, and as far as the Middle East, to utilize her reconstruction expertise.
Does insurance cover lumpectomies?
This federal law requires insurance plans that cover mastectomies or lumpectomies to also cover breast reconstruction. The WHCRA also includes surgery of the unaffected breast to produce a symmetrical appearance, as well as prostheses and treatment of physical complications from the treatment of breast cancer.
How often do breast reductions get covered by insurance?
In both Dr. Nwubah’s practice and Dr. Mahmood’s, about 80% of breast reductions are covered by insurance. Dr. Mahmood credits her insurance manager with achieving the high success rate, noting that “it’s very important to find a plastic surgeon who does a lot of breast reductions and whose team has experience with different insurance carriers and knows the ins and outs of every carrier and their individual plans, as plans within a carrier can differ greatly.”
What are the criteria for coverage of a breast reduction?
When seeking preauthorization for a breast reduction, your goal is generally twofold. You first need to demonstrate that the procedure is “medically necessary and therefore reconstructive rather than cosmetic,” says board-certified New York City plastic surgeon Dr. Umbareen Mahmood. According to Dr. Amaka Nwubah, a board-certified plastic surgeon in Nashville, Tennessee, insurance companies tend to define “medically necessary” as “impacting someone’s physical health, in the form of back pain—upper back pain is seen as more related to the breasts than lower—neck pain, and shoulder pain that significantly affect their quality of life and their ability to function.”
How can patients build a case for coverage?
As a first step, reach out to your primary care physician, to get your breast-related symptoms on the record and ask for referrals to providers who can assess and possibly try to treat those issues. “We recommend that patients establish care with a physical therapist, chiropractor, or orthopedist so there is documentation that they have sought medical management for their neck, back, and shoulder pain—and that these conservative treatments did not provide sufficient improvement in symptoms,” says Dr. Mahmood. Additionally, “they often need a note from a primary care physician, dermatologist, or gynecologist, reiterating their long-standing history of symptoms, including rashes in the breast folds.”
Why do some breast reduction requests get denied coverage?
Insurance carriers deny coverage for a variety of reasons, ranging from commonsense stuff, like contract exclusions and out-of-network physicians, to more frustrating factors, like spotty documentation; proposals to remove too little tissue; or failure to meet some element of the carrier’s criteria, such as not devoting ample time to alternative treatments—six months of physical therapy, say.
Can you perform breast reduction under insurance?
And this doesn’t sit well with some surgeons. “In my practice, I do not not perform breast reduction under insurance,” Dr. Stark tells us. In his opinion, operating according to Schnur math “can result in a breast that is not cosmetically ideal and [one that is], usually, too small for the patient,” he says. “When I approach a breast reduction, the goal is to remove the appropriate amount of tissue, to create a smaller but well-shaped and -positioned breast. The result should not be about weight but achieving the best-shaped breast for the patient.”
Does breast reduction help with anxiety?
Here’s How to Prove It to Your Insurance Company. A breast reduction shrinks more than just one’s cup size—it diminishes neck, back, and shoulder pain; abates rashes beneath the breasts; minimizes discomfort during exercise; and even decreases anxiety, depression, and body-image dissatisfaction, research shows.
Does insurance cover breast reduction?
In Dr. Nwubah’s experience, not every policy asks patients to check every box. “I have seen some insurance companies cover breast reductions based on my note and photos alone,” she says. “Every insurance company is different—but at the very least, a patient needs to have symptoms documented by their primary care provider.”
What are the complications of mastectomy?
Any physical complications at all stages of mastectomy, including lymphedema (fluid build-up in the arm and chest on the side of the surgery)
What is self insured insurance?
A self-insured (or self-funded) plan is one in which the employer, rather than a commercial insurance company, pays for the insured person’s health expenses. Some employers that self-insure will hire a commercial insurance company to write the checks and track the paperwork, even though the money for the payments still comes from the employer. So it can be hard to tell whether you are in a self-insured or a commercially insured plan unless you ask.
Does WHCRA allow insurance to penalize doctors?
No. The WHCRA does not allow insurance plans and insurance issuers to penalize doctors or lead them to provide care in a way that does not support the WHCRA. Nor does it allow insurance plans to reward doctors who do not encourage their patients to look into breast reconstruction.
Does a health insurance company cover a mastectomy?
Several states have their own laws requiring health plans that cover mastectomies to provide coverage for reconstructive surgery after a mastectomy. These state laws only apply to those health plans purchased by an employer from a commercial insurance company. If an employer is self-insured, state laws do not apply but federal laws do.
Does the Affordable Care Act change the WHCRA?
No. The WHCRA was not changed by the Affordable Care Act and there are no provisions or regulations that affect it. Health insurance plans that offer mastectomy must continue to offer breast reconstruction.
Does insurance cover mastectomies?
In most cases, yes, as long as the insurance plan also covers medical and surgical benefits for mastectomies. But certain church plans and government plans may not be required to pay for reconstructive surgery.
Does WHCRA prevent doctors from paying?
No. The WHCRA does not keep a plan or health insurance issuer from bargaining about amounts and types of payment with doctors. But the law does forbid insurance plans and issuers from penalizing doctors or providing incentives that would cause a doctor to give care that’s not consistent with WHCRA.