Does Insurance Cover A Preventative Mastectomy: NYSHIP and Other Options

A preventative, or prophylactic, mastectomy is often the best choice for women who face a particularly high risk of cancer. By removing one or both breasts, the patient can reduce their risk of breast cancer by up to 90% or more! Unfortunately, the answer to “Does insurance cover preventative mastectomies” isn’t straightforward because no federal law mandates this coverage. Luckily, some states require it—and New York is one of them. So yes, if you qualify, insurance should cover a preventative mastectomy.

When Does Insurance Cover Preventative Mastectomies?

For health insurance policies issued in New York State, insurers must provide coverage for “Medically necessary surgeries, including mastectomies and prophylactic mastectomies.” That means NYSHIP and other New York insurance policies will cover this procedure when someone is deemed high risk for breast cancer. But what is high risk? There are a few different criteria.

BRCA1 or BRCA2 gene mutations	Lobular carcinoma in situ Atypical hyperplasia	Family history
Genetic testing has brought these two harmful mutations into the light, allowing doctors to address them before the patient ever has to go through breast cancer. When these mutations are present, a bilateral prophylactic mastectomy is often indicated.	This is a condition characterized by abnormal cell growth in the breast that is not spreading but is a marker for increased breast cancer risk.	A strong family history of breast cancer, especially if multiple family members have been affected, could indicate a higher individual risk.
Previous breast cancer diagnosis	Radiation exposure	Other genetic and hereditary disorders
For individuals already diagnosed with breast cancer in one breast, a preventative mastectomy in the other may be considered to reduce the risk of a second cancer occurring.	Individuals who have received radiation therapy to the chest area at a young age (e.g., for Hodgkin’s lymphoma) may have an increased risk of breast cancer later in life.	Someone with Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome or with family members with these conditions may be at a higher risk of breast cancer.

Someone with one or more of the above markers would typically be considered high risk. As a result, their insurance does cover preventative mastectomies in New York State. But that’s not all it covers; breast reconstruction is often covered under insurance as well.

What About Breast Reconstruction?

The Women’s Health and Cancer Rights Act (WHCRA) was enacted in 1998, ensuring that insurance companies that provide coverage for mastectomies must also cover breast reconstruction procedures. This requirement is mirrored under New York Insurance Law § 3216, which mandates reconstruction coverage after any covered mastectomy. So if you’re in New York, not only does insurance cover a preventative mastectomy, it will cover your reconstruction as well. Even better, it’s required to cover the treatment path you want to follow. That includes choosing the type of surgery you get and who you decide to get it from.

Why a Plastic Surgeon Is Your Best Bet

While breast cancer is never easy, you’re in the best possible position you could be when you choose to get a preventative mastectomy. You’re not dealing with cancer yet, so you have time to make the right decisions for yourself and your body. It’s common to work with a team of healthcare professionals when undergoing a preventative mastectomy, including a breast surgeon and a plastic surgeon. But you don’t have to save that plastic surgeon for last! Consulting with them before you undergo the procedure can help in many different ways:

• Comprehensive Information: An experienced plastic surgeon will be able to provide detailed information about the various breast reconstruction options available. They can explain the pros and cons of each method, including implant-based reconstruction and autologous tissue (flap) reconstruction so that you can make an informed decision.
• Personalized Assessment: Each person’s anatomy, medical history, and needs are unique, and breast reconstruction is complicated. By meeting with a plastic surgeon, you can get a detailed assessment based on tailored recommendations.
• Improved Surgical Planning: When you involve a plastic surgeon early in the process, the surgical team can plan the preventative mastectomy and the subsequent breast reconstruction together. This collaborative approach ensures that the mastectomy is performed in a way that preserves the best options for reconstruction.
• Timing and Coordination: Preoperative consultations with a plastic surgeon allow better coordination between the breast and reconstructive surgeons. This coordination ensures that the mastectomy and reconstruction are scheduled to optimize the overall treatment plan and recovery process.
• Seamless Continuum of Care: Establishing a relationship with a plastic surgeon before the mastectomy creates a seamless continuum of care. The plastic surgeon can be part of your healthcare team from the start, ensuring that they understand your goals and preferences for reconstruction, even before the mastectomy occurs.

Does insurance cover a preventative mastectomy may be one of the first questions you should ask when you’re at risk for breast cancer, but it shouldn’t be the last. New York has a lot of great laws in place to protect women’s health. By working with the right medical team, you can make the most of your insurance coverage as you reduce your cancer risk.