Unhappy With Breast Reconstruction After Mastectomy? Next Steps With NYSHIP

Unfortunately, breast reconstruction isn’t always the end of a breast cancer battle. Many women are unhappy with their breast reconstruction after a mastectomy, whether immediately after or years later. They may have had a poor initial result or developed complications as they aged. Luckily for NYSHIP policyholders, some provisions ensure you have the right to revision breast reconstruction if you’d like to improve your results.

Unhappy with Breast Reconstruction after a Mastectomy? Here’s Why

Breast reconstruction following a mastectomy is a delicate process that involves working with already traumatized tissue. Even a perfectly performed surgery may have issues down the road, if not immediately after. To give you an idea, here are some of the various issues that you may face in the weeks or years following breast reconstruction surgery:

Condition	Description	When it occurs
Infection	Bacterial or fungal infection causing redness, pain, and swelling	0-1 years
Capsular Contracture	Scar tissue tightens around the implant, distorting the breast	0-10 years
Implant Displacement	Shifting or unnatural positioning of the breast implant	0-10 years
Implant Rupture/Leakage	Implant breakage or leakage of saline or silicone gel	0-15 years
Fat Necrosis	Death of fatty tissue resulting in lumps or hardness	0-1 years
Seroma Formation	Buildup of fluid around the implant causing swelling and pain	0-1 years
Late-Onset Infections	Infections occurring after the initial healing period	6-10 years
Biofilm Formation	Formation of a bacterial layer on the implant surface	8-10 years

If you’re unhappy with your breast reconstruction after a mastectomy, one of the reasons above is the likely culprit. Even the best surgery can result in complications down the road as your body ages and changes. That’s why insurance coverage for your revision breast reconstruction is built into the original policy language that covered your first surgery.

Getting Revision Breast Reconstruction Covered Under NYSHIP

If you’re unhappy with your breast reconstruction after a mastectomy, your NYSHIP policy will most likely cover a revision surgery. In fact, there are New York state and federal laws in place that require this coverage. Specifically, you’re dealing with two rules:

• The Women’s Health and Cancer Rights Act (WHCRA) of 1998: This act requires coverage for “treatment of physical complications of all stages of the mastectomy.” A poor result from a mastectomy would be considered one of these complications.
• New York Insurance Law § 3216: This state law also mandates coverage for all stages of breast reconstruction, with revision reconstruction being one of those stages.

These two laws protect your right to a revision if you’re unhappy with your breast reconstruction after a mastectomy. However, knowing these laws is a lot easier than navigating them. If you’re interested in breast reconstruction, here is what you need to do.

Consult with your surgeon

Before undergoing a revision breast reconstruction, it is crucial to consult a specialized surgeon with experience in this type of procedure. During the consultation, you will discuss the issues you are experiencing and the desired results you hope to achieve. It is important to provide specific details about your concerns and goals. The surgeon will take the time to get to know you and understand your expectations before conducting a thorough examination and creating a detailed surgical plan tailored to your individual needs.

Obtain supporting documentation

To demonstrate the medical necessity of your revision breast reconstruction, your surgeon will assist you in gathering relevant medical records. These may include details of your initial breast reconstruction surgery and related follow-up notes. These records are essential as they will help your surgeon understand the specifics of your previous surgery and adapt the best possible surgical approach for your revision.

Obtain a pre-authorization

Once your surgeon has developed a comprehensive surgical plan, their office will contact your NYSHIP insurance provider to inquire about the pre-authorization process for revision breast reconstruction surgery. Pre-authorization involves submitting the necessary documents, including the surgeon’s recommendations, to obtain approval from your insurance provider for the planned surgery. This step ensures that your insurance covers the procedure, subject to any applicable terms and conditions.

Review out-of-pocket costs

While insurance is typically required to cover the cost of your revision breast reconstruction surgery, it is important to be aware that there may still be some out-of-pocket expenses. These can include copays, co-insurance, or deductibles that you may be responsible for paying. To help you prepare financially, your surgeon’s patient care representative will guide you through the process and provide information about any anticipated out-of-pocket costs associated with your surgery. This step ensures that you clearly understand the financial aspects involved and can plan accordingly. You have options if you’re unhappy with breast reconstruction after a mastectomy. A skilled surgeon can perform a revision breast reconstruction, while an expert patient coordination team can cover the insurance side. Your NYSHIP policy includes the coverage you need to get the result you want; you just need to know how to use it.