Who Is Eligible for NYSHIP Revision Breast Reconstruction?

Both state and federal laws safeguard your right to undergo breast reconstruction surgery after a mastectomy or lumpectomy. If your initial reconstruction was covered, the same level of protection likely applies to revision breast reconstruction as well. In most cases, who is eligible for NYSHIP revision breast reconstruction will hinge on your prior coverage.

Eligibility For NYSHIP Revision Breast Reconstruction

A lot of people who need revision breast reconstruction didn’t necessarily have a poor result from their first surgery. It may have gone perfectly fine, leading them to believe that any revision breast reconstruction would be considered cosmetic and not covered. That is not the case.

In some cases, issues with breast reconstruction aren’t evident for months or years. It takes that much time for scar tissue to form and for the implants—if used—to settle. This is why there is a federal law in place to protect revision breast reconstruction.

The Women’s Health and Cancer Act of 1998 requires insurance plans—including NYSHIP—to provide breast reconstructive coverage for:

• All phases of breast reconstruction for the breast that underwent a mastectomy
• Breast reduction or reconstruction done on the non-affected breast to create a symmetrical appearance
• Prostheses (implants) and other permanent devices used to recreate the size and shape of the breast
• Treatment of physical complications resulting from a mastectomy

Revision breast reconstruction coverage typically falls into that first category, as a secondary reconstruction would be a phase of that surgery.

New York has similar laws that govern insurance coverage requirements in the state, meaning they also cover your NYSHIP policy. Under New York insurance law, any major medical insurance policy must include coverage for reconstructions related to mastectomies and reconstructions to achieve symmetry. Coverage for revisions is also required.

Of course, those laws are just the legal side of things. It’s also important to understand what revision breast reconstruction can address and what it can’t.

What Can Revision Breast Reconstruction Address?

While I advise all my patients to keep their expectations realistic, I’ve had great results in breast revision reconstruction for a wide range of issues. Some of the more common I’ve dealt with include:

• Pain
• Deformity and asymmetry
• Implant hardness
• Nipple displacement
• Chronic discomfort

Some of these issues only become evident years after surgery, but often, the patient realizes things are “not right” within the first three to six months after the initial reconstructive procedure. The deformity may result from lumpectomies or radiation therapy that causes “divots” in the skin that grow worse over time. Tension from scar tissue can create both nipple displacement and breast asymmetry, while prior implant placement could start to cause pain as the muscle heals in a tense position. All of these are issues that revision breast reconstruction can address.

Unfortunately, there are some things that it can’t correct completely. Some of these include:

• Loss of sensation: Sensation is a result of our nerve endings sending signals to our brains. Unfortunately, once those nerve endings are severed, it’s not usually possible to regain sensation. There are modern techniques that are used at the time of the initial reconstructive procedure that are designed to maintain or allow for more predictable “resensation,” or the return of sensation to the breast and nipple area.

• Complete scar removal: A good surgeon will work to minimize your scar as much as possible as well as hide it in less noticeable places like under the fold of the breast or around the areola. However, as this is a major surgery, there will always be some level of scarring. It is possible to revise these scars to smooth and even their appearance and make them less noticeable, though.

• Guaranteed future symmetry: Your breasts will continue to change as you get older, and they may do so at different rates. That’s why it’s also important to consider how the breasts may age differently in the initial surgical plan while attempting to get them as symmetrical as possible, especially if a preexisting asymmetry is identified. We often say “breasts are sisters, not twins.”

Despite those limitations, I’ve seen some great results from patients who are eligible for NYSHIP-covered revision breast reconstruction surgery. The key is focusing on your goal with surgery and working backward.

Choosing a Plastic Surgeon Under NYSHIP

Revision breast reconstruction can be a very complex procedure. When someone who is eligible under NYSHIP coverage starts their search, they typically look for in-network providers. However, this limits your pool to very few, and you may wind up on a long waiting list.

You also have the option of going with an out-of-network provider. That immediately expands your pool and gives you a little more room to negotiate bills. A provider who’s out of network does not have a contract with agreed billing rates with your insurance company. It doesn’t mean they won’t work with them, nor does it mean your out-of-pocket costs have to be significantly higher.

In many cases, the doctor’s office is willing to work with the patient to control those expenses because the coverage is statutory. It must be given, and there’s a high demand for revision breast reconstruction and not a lot of specialists. In the best interest of their patients, doctors have to be willing to work with insurance companies. So, if you want to get a great result, don’t be afraid to expand your options to out-of-network providers. A good practice will walk you through any out-of-pocket costs upfront so you know what to expect.

Once you’re ready to start looking at plastic surgeons, here are some questions to consider asking:

What revision breast reconstruction options would help me reach my goal?

Revision breast reconstruction is not a one-size-fits-all approach. Less invasive procedures like autologous fat grafting—where fat is harvested from a donor site and used to fix deformities—may be enough to refine the results. In other cases, a more extensive surgery where the implant is removed, replaced, and reseated is needed to obtain the result you want. It’s all about your goals—and your surgeons’ capabilities.

How many of these procedures have you done?

Revision breast reconstruction is already a complex procedure because you’re dealing with existing trauma and scar tissue. You will want to work with a surgeon who has extensive experience and specializes in the type of surgery you need.

Will it be an inpatient or outpatient procedure?

Ideally, your surgeon will be able to complete your procedure on an outpatient basis. That means you don’t require a hospital stay. You can recover at home and likely return to normal activities faster than with a more extensive inpatient surgery.

What kind of results can I realistically expect from the revision?

Your surgeon should be able to provide realistic expectations for what kind of results you can expect from the revision, based on your unique anatomy and the specific revision technique(s) they plan to use.

How long will my recovery be?

Many of our patients work strenuous jobs in the public sector. They need to make the recovery period work with their schedule. Knowing the expected recovery for your specific surgery will help you plan out the timeline.

What are my expected out-of-pocket costs?

As insurance coverage for revision breast reconstruction is mandated by law, you want to work with a plastic surgeon’s office that understands the ins and outs of it and how it affects your specific policy. Someone should provide you with a detailed understanding of what your out-of-pocket costs will be after the doctor has created a customized surgical plan for you.

Determining who is eligible for NYSHIP revision breast reconstruction is relatively easy because it’s written right there in the law. If it’s related to a mastectomy or lumpectomy, it’s very likely covered. While no one can give you a “yes” or “no” answer without understanding the details of your specific case, know that any good surgeon will work with you to get you the care that you’re entitled to under your policy.