What Does the Empire Plan Cover? A List of Plastic Surgery Options

While Joanne, our practice manager, is usually the one who answers questions about what the Empire Plan covers, there are parts within the answers where I can assist. Insurance is the funding for your surgery; what’s really important is why you need it. A lot of my patients have seen massive improvements in their quality of life following procedures that are typically considered elective—and many of those procedures were covered by their Empire Plan. 

It’s my job to help guide patients by telling them about their options and what kind of improvements they can expect to see. I get to know them so I can understand their backgrounds, activity levels, life goals, and overall health. While the Empire Plan does cover a range of plastic surgery procedures, it all boils down to what’s considered medically necessary. When contemplating breast reconstruction and revision breast reconstruction, insurance coverage under the Empire plan is guided by federal and New York state laws. 

What Does Empire Plan Cover? 

The answer to the question “What does the Empire Plan cover?” is: “It varies.” 

The Empire Plan covers just about any plastic surgery procedure—as long as your surgeon has determined it to be a medical necessity. Here are a few examples: 

• Breast reduction
• Breast reconstruction
• Revision breast reconstruction
• Functional rhinoplasty (correction of poor breathing)
• Mohs reconstructive surgery
• Scar revision surgery 

How Empire Plan decides what is medically necessary changes depending on the type of surgery. However, there are a few procedures that I do where medical necessity is justified by clinical history (such as breast reduction) or based on the fact that the reconstructive procedures are for restoration of form and function following cancer surgery, such as revision breast reconstruction and Mohs surgery reconstruction. 

For a more in-depth look at what the Empire Plan covers, Joanne gives a detailed review of NYSHIP plastic surgery options. 

Here, I’ll detail three of our office’s most common procedures, why we do them, and why Empire Plan covers them. 

Medically Necessary Breast Reduction and Reconstruction Surgeries

There’s a bit of overlap between breast reduction and breast reconstruction surgery, so it’s not unusual to talk about them together. However, the medical necessity determination for these surgeries is very different. While breast reduction surgery can be very subjective on coverage, some breast reconstructive surgery coverage is protected by law.  

Breast Reduction 

Most of my breast reduction patients aren’t heavily focused on how they look—though of course, that’s a concern. Their problem is the way they feel. Excessive breast tissue, sometimes called macromastia and gigantomastia, can really affect your Activities of Daily Living (ADLs). 

That phrase you might often hear when you’re getting treatment for a chronic problem. Activities of daily living are just that: taking a shower, cooking a meal, playing with your kids, going to the gym, or taking the stairs at work. These are all activities that most people can do without problems each day. 

Someone with macromastia or gigantomastia may not be able to do those things easily. They may have to adjust those activities or stop doing them altogether. They may avoid taking the stairs due to discomfort or stop playing with their kids because of chronic neck, back, or shoulder pain. That’s the first stop when it comes to determining medical necessity; how is your daily life going to be improved by surgery? Have non-surgical options provided only temporary relief of your symptoms?

The next thing to consider is whether surgery is the best—sometimes only—way a chronic condition will improve. A good example of this is something called thoracic outlet syndrome (TOC). When you have a lot of breast tissue, it can pull the muscles in the chest wall forward, impinging on a cluster of nerves and blood vessels called the thoracic outlet. That pressure can lead to a lot of different issues, like neck pain, back pain, tingling in the arms and fingers, and even headaches. 

If the cause of the TOC is excess breast tissue, no exercise, medication, or diet plan in the world will resolve it alone. The best possible way is to remove the continuous cause of the problem—the excess tissue—through breast reduction.

Of course, that’s just one example. While what Empire Plan covers will have specific criteria, the crux of it all lies in medical necessity. Breast reconstruction, however, is a bit more straightforward.  

Breast Reconstruction 

Breast reconstruction is a surgery used to rebuild your breast after a mastectomy. This can be done through implant reconstruction, flap (natural tissue) reconstruction—where a patient’s living skin is used to reform the breasts—or a combination of both.

Under the Women’s Health and Cancer Rights Act (WHCRA) of 1998, all reconstructive surgeries relating to mastectomies are covered. That’s across all insurance plans, Empire included. That coverage applies to cancer-related mastectomies and mastectomies done to prevent cancer. For most women looking for breast reconstruction surgery, this information may be pretty well-known.

What’s less known is revision breast reconstruction is also covered. Many women who have breast reconstruction surgery become dissatisfied with their results after some time. Something I see a lot is the hardening or displacement of their implants. It’s not the implants that get hard; it’s the scar tissue around them. Scar tissue can cause them to stretch and tighten, resulting in implants that feel stiff and unnatural. 

Scar tissue formation can also be a problem for breast symmetry. How the scar tissue forms in one breast may not be identical to how it forms in another, resulting in one breast that is a different size, shape, or position from the other. The problem with both issues is that they’re not immediately evident after the surgery. They can take years to form. 

I also see women who have chronic discomfort of the breasts after implant reconstruction when the implant has been placed partially under the muscle. This can result in a “dynamic deformity,” or a deformity that is worsened when the muscle is contracted. Revision surgery, which places the implants in front of the muscle (PRE pectoral), can often improve symptoms dramatically.

Therefore, many women assume because it’s been years since they had their breast reconstruction, they’re on their own when it comes to revision. That’s not necessarily true. If your reconstruction was originally covered as part of a mastectomy, then your revision breast reconstruction may be covered as well.

Mohs Reconstruction for Skin Cancer 

Mohs surgery is a procedure performed by a specialized dermatologist to remove skin cancer. The dermatologist treating the skin cancer must remove the skin layer by layer until they reach a layer where no cancerous tissue remains. Of course with a process like that, you’re going to have a scar. It may even be disfiguring—as skin cancer can affect the thin skin around the eyes, nose, or lips. 

When that happens, I collaborate with the dermatologist to perform Mohs reconstruction surgery. After performing a complete examination of the biopsied area, I create a plan that involves either direct closure, skin grafting, or flap reconstruction to return the skin to its normal appearance. This is considered a covered surgery under the Empire Plan.

The list of what the Empire plan does cover is pretty extensive when it comes to medically necessary plastic surgeries. I see them all the time, whether it’s patients who want to improve their quality of life through breast reduction or recover from a life-altering illness with revision breast reconstruction or Mohs reconstruction surgery. To completely understand your coverage options, I always recommend you come in and meet with Joanne.