NYSHIP: Who’s Eligible for Breast Reconstruction?

Someone who has had a mastectomy relating to breast cancer is also someone who’s eligible for breast reconstruction.

If you have undergone a mastectomy or lumpectomy for breast cancer or prophylactic breast removal because of a genetic predisposition to breast cancer, you may be someone who’s eligible for breast reconstruction under your NYSHIP insurance policy. This type of surgery can help you restore the shape, size, and appearance of your breasts following a mastectomy. For many women, it’s an important part of their recovery from cancer. It’s also a protected procedure under federal and New York state laws, meaning that insurance coverage is mandated for breast reconstruction as well as for revision breast reconstruction.

Who’s Eligible for Breast Reconstruction? NYSHIP Criteria

NYSHIP, like most insurance carriers, is required to provide coverage for breast reconstruction by the Women’s Health and Cancer Rights Act (WHCRA) of 1998. This act requires both employer-sponsored and private health insurance policies to cover:

  • All stages of reconstruction of the breast on which the mastectomy has been performed;

  • Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

  • Prostheses and treatment of physical complications of all stages of the mastectomy, including lymphedema.

The WHCRA requires this coverage when the lump or mastectomy is related to a cancer diagnosis as well as in cancer prevention. Our ability to detect certain types of breast cancer in women has grown since the act was written in 1998. Today, women can have genetic testing to determine if they carry certain markers that put them at high risk for breast cancer. If they do, a preventative mastectomy can help them reduce their risk. The WHCRA also applies to that.

New York has its own laws regarding what insurance carriers must cover when it comes to breast reconstruction. In fact, the New York Insurance Law § 3216 is nearly identical to the WHCRA.

Every  policy  which  provides  medical,  major medical, or similar comprehensive-type coverage shall provide the following coverage for  breast  reconstruction  surgery  after  a  mastectomy or partial mastectomy:

  1. All stages of reconstruction of the breast on which the mastectomy or partial mastectomy has been performed; and

  2. Surgery and reconstruction of the other breast to produce a symmetrical appearance.

Finally, there are laws in place that require medical providers to give you information regarding your rights to breast reconstruction and the types of surgical options available. The Breast Cancer Patient Education Act of 2015 was created to help raise awareness about these types of procedures and your options. For simplicity’s sake, there are four broad ways of completing a breast reconstruction:


Implant-Based Reconstruction


Autologous Reconstruction





Implant-based reconstruction involves the use of silicone breast implants to rebuild the breast. The surgeon creates a pocket in the chest muscle and places the implant inside. This type of reconstruction may involve multiple stages but can sometimes be performed as a direct-to-implant reconstruction.Sometimes called flap-based reconstruction, this procedure uses tissue from another part of your body to rebuild the breast.The most common donor sites involve excess skin from the abdominal wall. The benefit of this approach is that the patient doesn’t face any of the ongoing risks that come with implants like rupture or hardening.This method combines autologous reconstruction with implants to recreate the breast shape and add volume, improving the overall result. More frequently, techniques involving fat transfer from one part of the body into the breast are being performed, which can improve the results from flap or implant surgery.In oncoplastic surgery, advanced plastic surgical techniques are used to reshape the breast after lumpectomy. These can involve breast lifting or breast reduction type procedures that will reshape the remaining breast after lumpectomy, minimizing the risk of deformity after radiation. These techniques can be performed at the time of lumpectomy or as corrective techniques for unfavorable breast conservation surgery

One of the biggest benefits of breast reconstruction protection laws is that the type of surgery you choose is between you and your doctor. The insurance company isn’t allowed to step in and delegate which surgeries they’ll cover or won’t cover. Your choice of surgery is up to you. That’s true for breast reconstruction, and it’s also true for revision breast reconstruction.

What About Revision Breast Reconstruction? 

There is a big misconception about breast reconstruction in general. People who haven’t had the procedure assume that it’s a “one and done” kind of thing. But that’s not true. Very often, a revision breast reconstruction will be necessary to tweak the final result for symmetry. 

Implants aren’t designed to last forever. They can rupture, meaning they have to be removed and replaced. In addition, our bodies change and shift as we age, which can cause changes to the scar tissue and the appearance of the breast. Patients may notice over time that their breasts are asymmetrical, hard to the touch, or dimpled and stretched from their scars. They may even have pain from how their chest muscle healed around the implant if one was used.  For women who have had breast conservation surgery, deformities related to the effects of radiation can cause depressions in the breast contour or changes in the position of the nipple and areola. 

None of that means that their original breast reconstruction was incorrectly done. Even a perfectly performed procedure could have some issues down the road. Luckily, the laws I discussed above account for this. If your first breast reconstruction was covered by your insurance, then your revision breast reconstruction is very likely covered as well.

NYSHIP is a reputable and respected insurance provider, so they follow the letter of the law when it comes to who is eligible for breast reconstruction. Whether you have a recent cancer diagnosis and want to return to some level of normalcy through breast reconstruction or had one years ago and are dissatisfied with your results, you may be covered. The best way to find out is to ask. Schedule a consultation with a qualified plastic surgeon to determine your eligibility.

Bringing Patient Advocacy to Breast Reduction and Reconstruction

Harris Plastic Surgery is a top provider of breast reconstruction and revision reconstruction services. To find out if you’re someone who’s eligible for breast reconstruction surgery, contact us and schedule a consultation.

Stephen U. Harris, MD FACS

Dr. Stephen U. Harris is a board-certified cosmetic surgeon and recognized expert in breast reduction and reconstruction surgeries, having performed thousands in his career. When it comes to patient care, his philosophy is that every surgery should improve his patient’s overall quality of life, not just their appearance. Dr. Harris stays up-to-date on all the latest advancements in breast augmentation, reconstruction, and reduction and is a recognized innovator in the field. In fact, he was the first surgeon at Good Samaritan Hospital to offer primary prepectoral implant breast reconstruction, as well as secondary prepectoral revision surgery.

Dr. Harris also serves as Chief of Plastic Surgery at Good Samaritan Hospital in West Islip, New York and is an active staff surgeon (and former Chief of Plastic Surgery) at South Shore University Hospital in Bay Shore, New York.

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