Does Insurance Cover Breast Reconstruction?

Breast augmentation Long Island

If you’re wondering, “Does insurance cover breast reconstruction?” you’ll be relieved to hear that the answer is “yes” for many people. If you’ve undergone a cancer-related mastectomy, you have certain legal rights regarding breast reconstruction. Your insurance must follow these rules. Here’s what you need to know about breast reconstruction requirements under your insurance policy.

Does Insurance Cover Breast Reconstruction? Your Legal Rights

While we often refer to NYSHIP insurance for breast reconstruction eligibility, you should know it’s pretty much the same across carriers.  That’s because companies that offer insurance policies in New York are required to follow two laws related to these procedures. 

The Women’s Health and Cancer Rights Act (WHCRA) of 1998


New York Insurance Law § 3216

Coverage must be provided for:

  • 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.

Coverage must be provided for: 

  • All stages of reconstruction of the breast on which the mastectomy or partial mastectomy has been performed; and
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance.

Aside from coverage laws, you also have a right to another critical part of recovering from breast cancer surgery–information. Under the Breast Cancer Patient Education Act of 2015, you have a right to details “regarding the availability and coverage of breast reconstruction, prostheses, and other options.” 

In short, insurance isn’t just required to cover breast reconstruction. It’s required to cover the procedure you and your surgeon think is best. 

Your Options for Breast Reconstruction Surgery

If you’ve dealt with insurance companies before, you know they can be a bit nit-picky. They may agree to cover one type of treatment but not another. That is not the case in breast reconstruction. Your insurance company must cover the procedure you and your doctor think is best. Here are some typical approaches to breast reconstruction surgery. 

Implant-Based Reconstruction

Implant-based reconstruction is pretty straightforward. An implant is used to recreate the breast mound following a reconstruction. In some cases, this is done as a multi-stage process, where a temporary implant is placed at the time of the surgery and then replaced with a permanent implant later. In other cases, a direct-to-implant reconstruction will be possible at the time of mastectomy.

Benefits:

  • Provides immediate breast shape and volume.
  • Shorter surgical time and recovery compared to autologous reconstruction.
  • Options for different types and sizes of implants.
  • Can be combined with nipple reconstruction for complete breast reconstruction.

Autologous Reconstruction

Sometimes called flap-based reconstruction, this procedure uses tissue from another part of your body to rebuild the breast. The most common donor site is the abdominal wall, though the thighs, back and buttocks are also used. The patient doesn’t face any of the ongoing risks that come with implants, like rupture or hardening.

Benefits:

  • Uses the patient’s own tissue for a natural and long-lasting result.
  • Result ages with the patient.
  • Avoids the need for long-term implant maintenance or potential implant-related complications.

Hybrid

This method combines autologous fat grafting with implants to recreate the breast shape and add volume, improving the overall result. , techniques involving fat transfer from one part of the body into the flap tissue used to reconstruct the breast mound can be performed, which can improve the results from flap surgery.  In many cases, fat grafting is performed with implants to smooth the transition to the implant mound or to add thickness to the skin overlying the implant for a more natural appearance.

Benefits: 

  • Combines the benefits of both implant-based and autologous reconstruction techniques
  • Provides a more customized approach to suit individual patient needs
  • Allows for flexibility in adapting the procedure to accommodate different breast sizes and tissue availability

Oncoplastic

In oncoplastic surgery, advanced plastic surgical breast reshaping techniques are used to reshape the breast during a lumpectomy or partial mastectomy. Oncoplastic surgery aims to provide patients with cancer treatments that address the disease and help restore or enhance their breast tissue.  Many of these oncoplastic procedures use breast reduction or breast lift

patterns to create a smaller lifted breast contour while avoiding the depression deformity that can result from a lumpectomy alone.

Benefits:

  • Combines cancer removal (partial mastectomy) with breast reconstruction in a single surgery.
  • Preserves the natural shape and contour of the breast.
  • Reduces the need for additional surgeries and improves overall aesthetic outcomes.

Revision breast reconstruction

A revision breast reconstruction is a procedure done to correct the results of a prior reconstruction. Sometimes, you have poor results from your initial surgery. Others, you don’t start to discover issues until years later. In both cases, revision breast reconstruction is covered under your insurance policy. 

This procedure combines many of the above surgical approaches into a surgery designed to correct a prior breast reconstruction. These procedures can be quite complex, and working with a highly experienced plastic surgeon is best.

Insurance does cover breast reconstruction when it’s related to a mastectomy. If you’re considering your options, know that you have the right to pursue the treatment and surgical paths that you think are best. At Harris Plastic Surgery, we can walk you through both your medical and insurance coverage options so you can make an informed decision. 

Would you like to learn more about insurance coverage for breast reconstruction surgery?

Contact our office for a consultation.

Joanne Parrinello, Practice Manager

Joanne Parrinello is an expert patient care coordinator, with two decades of experience navigating the complex financial side of medically necessary breast reduction and reconstruction surgery. She acts as a guide to patients, helping them understand their options and their expected out-of-pocket expense. The insurance industry can be complex and filled with jargon that makes you feel like you need a translator. At Harris Plastic Surgery, Joanne is that translator.

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