Is breast reconstruction surgery covered by insurance?

Is breast reconstruction surgery covered by insurance? | Chicago Plastic SurgeryBreast cancer patients would want to understand whether their medical insurance plan will cover the costs of their breast reconstruction plastic surgery. The answer is ‘yes’ in many cases.

However, patients should ideally discuss matters related to insurance coverage with their breast surgeon and insurer in advance of the procedure.

Board certified plastic surgeon Dr. Jacob Bloom provides breast reconstruction to patients in Chicago, IL, and surrounding locations.


Main Facts about Breast Reconstruction Insurance

Insurance coverage differs on a case by case basis. However, certain facets of breast reconstruction plastic surgery are fairly standard.

The Women’s Health and Cancer Rights Act (WHCRA) mandates that insurance plans must provide coverage for breast reconstruction surgery following a mastectomy.

In case the breast reconstruction is undertaken after a preventive mastectomy, the patient will still be eligible for insurance coverage in most cases, provided that she is considered at high risk for developing breast cancer.

According to the Women’s Health and Cancer Rights Act of 1998, every group insurance plan that provides coverage for a mastectomy must pay for the reconstructive surgery and prostheses as well. In addition, Medicare also covers breast reconstruction. However, Medicaid coverage may vary between states.


Check Insurance Aspects Beforehand

Even in cases when a patient has insurance coverage for breast reconstruction, it is possible to encounter problems in specific situations.

For example, if the patient chooses to undergo a newer reconstructive technique in order to develop a more balanced breast appearance or needs revision of a previous reconstruction, she may face some hiccups in insurance coverage.

Another area of concern could be if the patient chooses to work with a cosmetic surgeon who is not included in the network of her medical insurance plan.

The patient should discuss the situation with her insurer ahead of the surgery to determine what is covered so that she can make well-informed choices. The surgeon’s staff may also be able to guide the patient on insurance claims.

Patients may also check with the medical insurance agency and commissioner in their state to understand the regulations governing breast reconstruction cosmetic surgery.


Questions to Ask

The patient may use the following questions as a guide during her discussions with the insurance provider and the surgeon’s staff regarding insurance coverage for breast reconstruction surgery:

  • Does my health plan offer coverage for mastectomy? (if yes, it will cover breast reconstruction by default)
  • How can I acquire pre-authorization for my breast reconstruction plastic surgery?
  • Does my medical plan restrict my choices to in-network surgeons and services?
  • If I decide to work with a surgeon who is not included in my network, what costs will still be eligible for coverage?
  • If I choose a surgeon who is not within my network, what will my out-of-pocket expenses be?
  • Does my insurance plan offer coverage for a hospital stay? If yes, for how many days?
  • Does my plan cover other medical professionals involved in my procedure?
  • Will the bills be paid directly to providers?

The patient should understand that she will still be responsible for paying for co-pays and deductibles and have clarity on how much she will need to pay out of pocket.


Planning Ahead

The insurance claim process should commence well in advance of the surgery if the patient has sufficient time to plan for the mastectomy and breast reconstruction. Patients who do not have insurance coverage may seek financing from various options such as loans from professional medical care finance firms.

Cosmetic surgeon Dr. Jacob Bloom receives patients from Chicago, IL, and nearby areas for breast reconstruction.