Does Insurance Cover Preventative Mastectomy and Reconstruction?

When certain risk factors are detected, insurance does cover preventative mastectomy and reconstruction or enhanced screening, depending on your preferences.

Does insurance cover preventative mastectomy and reconstruction? Most often, it does. This surgery is done to significantly reduce your chance of getting breast cancer in cases where you may face genetic or physical predispositions. The mastectomy and reconstructive process is considered medically necessary under state law, and your insurance coverage must cover it.

Of course, that’s if you decide to go this route. The decision is a personal one that can only be made by you. However, your doctor should be happy to guide you through your options. Here, I’ll delve into the decision-making process, insurance coverage criteria, and the significance of involving a plastic surgeon.

Should You Get a Preventative Mastectomy?

Only you can determine if a preventative mastectomy is the right choice for you. It’s not your only option. When you’re presented with a high-risk diagnosis, your doctor should outline two paths; monitoring and surgery.

Monitoring

Surgery

This approach involves regular medical check-ups, screenings, and close surveillance to monitor any changes in breast health.

This involves the surgical removal of both breasts, reducing the risk of developing breast cancer. This may be done as a nipple-sparing or skin-sparing mastectomy, depending on your particular situation

Pros

Non-invasive: It doesn’t require surgery or the associated recovery time.

Preserves breast tissue: You maintain your natural breasts.

Potential peace of mind: Some individuals feel reassured by regular monitoring.

Cons

Risk of missed cancer: There is a chance that cancer may develop and be detected at a later stage.

Ongoing anxiety: The need for frequent monitoring can cause anxiety and stress.

Potential for more aggressive treatment later: If cancer is detected, it may require more extensive treatment.

Pros

Significant risk reduction: Preventative mastectomy can substantially reduce the risk of breast cancer in high-risk individuals.

Peace of mind: Some people feel a sense of control and reduced anxiety after the surgery.

Potential for reconstruction: Reconstruction can provide aesthetic and emotional benefits

Cons

Surgery and recovery: It’s an invasive procedure with recovery time and potential surgical complications.

Loss of breast(s): Mastectomy results in the removal of breast tissue, which can have emotional and physical effects, which is why immediate breast reconstruction is a vital part of the process of prophylactic treatment

Not foolproof: While highly effective, there is still a small residual risk of developing breast cancer.

Does Insurance Cover Preventative Mastectomy and Reconstruction?

Insurance will cover preventative mastectomy and reconstruction when it’s determined that you have a high risk of developing breast cancer. That is decided when one or more of the following factors are present;

  • Known genetic predisposition to breast cancer. Individuals testing positive for BRCA1 or BRCA2 gene mutations (or other known genetic markers identified to predispose to high-risk of developing breast cancer) often qualify for insurance coverage as these two genes are associated with a higher prevalence of breast cancer rates.
  • Family history. A strong family history of breast cancer, particularly with multiple affected family members, can be a determining factor for insurance coverage.
  • Prior breast cancer diagnosis. If an individual has previously been diagnosed with breast cancer and is at high risk for recurrence or developing cancer in the opposite breast, insurance may cover preventative mastectomy and reconstruction as part of a risk-reduction strategy.
  • Lobular carcinoma in situ (LCIS). LCIS is a condition characterized by abnormal cell growth within the milk-producing lobules of the breast. While it’s not invasive cancer, it is considered a marker for an increased risk of developing breast cancer, and insurance may cover preventative measures in such cases.
  • Atypical hyperplasia. Atypical hyperplasia refers to abnormal cell growth in the breast tissue, which is not cancer but carries an elevated risk of developing breast cancer. Insurance may consider coverage in situations where atypical hyperplasia is present.
  • Radiation exposure. Individuals who have a history of significant radiation exposure to the chest area, such as prior radiation therapy for other medical conditions, may be eligible for insurance coverage for preventative mastectomy and reconstruction.
  • Prior breast cancer diagnosis. If an individual has previously been diagnosed with breast cancer and is at high risk for recurrence or developing cancer in the opposite breast, insurance may cover preventative mastectomy.

If any of these are present, then your risk of breast cancer is elevated, and it will be considered medically appropriate to complete a mastectomy and reconstruction. Both of these will be covered under your insurance policy. That coverage applies to your preferred surgical path; that’s why so many patients choose to let a plastic surgeon direct their entire process.

Why a Plastic Surgeon Is the Best Choice to Guide Your Care

The role of a plastic surgeon is pivotal in managing the preventative mastectomy and reconstruction process. Many patients choose to make the plastic surgery consultation the first stop in their journey. Ultimately, the decision to have a preventative mastectomy is a brave and empowering choice, and the final aesthetic appearance of the breast should be a primary concern.The plastic surgeon connects them with the breast surgeon and then works with them to perform the reconstruction at the time of mastectomy. This comprehensive approach provides three major benefits to our patients;


Expertise

Financial Guidance

Treatment Continuity

Plastic surgeons provide comprehensive information about various mastectomy and breast reconstruction options, ensuring individuals can make informed decisions. The plastic surgeon can use specialized techniques to enable a nipple-sparing procedure when it might otherwise be difficult based on preexisting breast drooping.

A plastic surgeon with a strong insurance coordination team can navigate the verification process to maximize your coverage and reduce your out-of-pocket expenses.

Collaboration between plastic surgeons and the surgical team ensures that mastectomy and reconstruction are scheduled simultaneously and executed to optimize overall treatment and recovery.

Insurance does cover preventative mastectomy and reconstruction, but that’s probably not the only question you have. Making the decision to undergo a preventative mastectomy is a significant step in reducing breast cancer risk. A good plastic surgeon can help assist you in making informed choices about your health and your well-being

Bringing Patient Advocacy to Breast Reduction and Reconstruction

Are you considering insurance-covered preventative mastectomy and reconstruction? Contact Harris Plastic Surgery for help navigating the process. 



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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