Date February 5, 2016
Categories Breast Reconstruction Cosmetic Surgery
Fox Valley Plastic Surgery works with general and breast surgeons throughout Northeast Wisconsin to provide breast reconstruction after mastectomy. Our plastic surgeons also care for patients who develop implant-related problems, breast asymmetry, or other concerns years after their original reconstruction.
Some patients live with discomfort or changes in their reconstructed breasts because they do not realize that their health insurance may cover medically necessary follow-up care. Federal law provides important protections for many patients through the Women’s Health and Cancer Rights Act of 1998, commonly called the WHCRA.
What Is the Women’s Health and Cancer Rights Act?
The Women’s Health and Cancer Rights Act is a federal law that establishes coverage protections for patients undergoing mastectomy and breast reconstruction. In general, when an applicable health plan covers a mastectomy, it must also provide coverage for certain reconstructive services related to that mastectomy.
These protections generally include:
- Reconstruction of the breast affected by the mastectomy
- Surgery and reconstruction of the other breast to create a more symmetrical appearance
- Breast prostheses needed before or during reconstruction
- Treatment of physical complications at any stage of a mastectomy, including lymphedema
Coverage must be provided in consultation with the patient and the attending physician. The law does not require a patient to undergo reconstruction, nor does it dictate which type of breast reconstruction must be selected.
Does Insurance Cover Breast Reconstruction Years Later?
Breast reconstruction does not always end after the initial surgery. Patients can develop complications or changes months or years later, including:
- Breast implant rupture or leakage
- Capsular contracture
- Implant displacement
- Breast asymmetry
- Changes caused by aging or weight fluctuations
- Pain or tightness around an implant
- Problems with a tissue flap
- Lymphedema
- The need to revise the opposite breast to improve symmetry
The WHCRA does not limit its protections to reconstruction performed at the same time as a mastectomy. Medically necessary revision surgery or treatment of physical complications may qualify for coverage even years later.
However, coverage is not automatic. The insurance company may require medical records, photographs, imaging, prior authorization, or other documentation showing that the procedure is medically necessary and related to the mastectomy or reconstruction.
Does Insurance Cover Replacement of a Ruptured Breast Implant?
An insurance plan may cover removal and replacement of a ruptured implant when the implant was placed as part of breast reconstruction following a medically necessary mastectomy. Coverage can depend on the patient’s health plan, medical necessity, documentation, network requirements, and prior-authorization rules.
This differs from implants originally placed for elective cosmetic breast augmentation. Health plans generally exclude treatment related solely to cosmetic breast implants, although coverage circumstances vary.
Patients who suspect an implant problem should schedule an evaluation rather than assuming they must pay for treatment themselves.
Does WHCRA Coverage Include the Other Breast?
Yes. When an applicable plan provides mastectomy coverage, the WHCRA requires coverage for surgery and reconstruction of the opposite breast when needed to create a symmetrical appearance.
Depending on the patient’s anatomy and reconstructive plan, this could include an appropriate procedure such as a breast lift, reduction, augmentation, or another form of reconstruction. The patient and treating physicians determine the appropriate care, subject to the plan’s coverage requirements.
Can Insurance Apply a Deductible or Coinsurance?
Yes. Breast reconstruction coverage may still be subject to the plan’s usual:
- Annual deductible
- Copayment
- Coinsurance
- Provider-network requirements
- Prior-authorization procedures
A health plan cannot impose deductibles or coinsurance for WHCRA-protected care that are inconsistent with those applied to other medical and surgical benefits under the plan.
Patients should ask their insurance company for a written explanation of benefits and estimated financial responsibility before surgery.
Must My Insurance Company Tell Me About WHCRA Benefits?
Applicable health plans and insurers must provide information about WHCRA protections when a patient enrolls and annually afterward. The notice may appear in enrollment materials, plan documents, annual notices, newsletters, or other plan communications.
If you cannot locate the notice, contact your insurer or employer’s benefits administrator and ask specifically about mastectomy-related breast reconstruction benefits under the WHCRA.
Can an Insurance Plan Discourage Breast Reconstruction?
The WHCRA prohibits applicable health plans and insurers from denying eligibility or discouraging enrollment or renewal to avoid providing required breast reconstruction benefits.
Plans also cannot penalize healthcare providers or offer incentives intended to discourage care that is protected under the law.
How Does Wisconsin Law Affect Breast Reconstruction Coverage?
Wisconsin has additional insurance requirements related to breast reconstruction and prosthetic devices following mastectomy. Whether Wisconsin law applies depends partly on how the health plan is funded.
An employer-sponsored plan may be:
- Fully insured: The employer purchases coverage from a health insurance company. State insurance requirements generally apply.
- Self-funded: The employer pays employees’ medical claims, although an insurance company may administer the plan. Federal law generally governs these plans, and state insurance mandates may not apply.
Because the insurance company’s name may appear on both types of cards, it is not always obvious whether a plan is fully insured or self-funded. Ask your employer’s benefits administrator or plan administrator if you are unsure.
Do WHCRA Requirements Apply to Medicare or Medicaid?
The WHCRA does not directly apply to Medicare or Medicaid. These programs have their own coverage requirements.
Medicare considers reconstruction of the affected breast and the opposite breast following a medically necessary mastectomy to be noncosmetic care that may qualify for coverage. Medicaid coverage and administrative requirements can vary by state and program.
Patients with Medicare or Medicaid should verify coverage and authorization requirements directly with their plan.
What Should I Do If My Breast Reconstruction Claim Is Denied?
An initial denial does not necessarily mean the requested treatment is excluded. The insurer may need additional medical records, photographs, imaging, or documentation explaining how the procedure relates to the mastectomy or reconstruction.
If your claim or prior-authorization request is denied:
- Request the denial and its reason in writing.
- Ask for the specific plan provision or medical policy used in the decision.
- Review your plan’s WHCRA notice and breast reconstruction benefits.
- Ask your surgeon whether additional medical documentation can be submitted.
- Follow the plan’s internal appeal process.
- Contact your employer’s benefits administrator or the appropriate insurance regulator if necessary.
Breast Reconstruction and Revision Surgery in Wisconsin
You do not necessarily have to live with pain, implant complications, asymmetry, or another problem simply because many years have passed since your mastectomy and breast reconstruction.
Fox Valley Plastic Surgery provides breast reconstruction and revision surgery for patients in Oshkosh, Appleton, Green Bay, Fond du Lac, Neenah, and surrounding Wisconsin communities. Our team can evaluate your concerns, discuss possible treatment options, and help gather the clinical documentation your insurer may require.
Contact Fox Valley Plastic Surgery at 920-233-1540 to schedule a breast reconstruction consultation.
This article provides general educational information and is not legal advice or a guarantee of insurance coverage. Benefits, exclusions, medical-necessity requirements, provider networks, and patient cost-sharing vary by health plan. Patients are responsible for verifying their individual coverage.