Insurance-Based Reconstruction and Revision

researchPatients who have undergone breast cancer surgery (mastectomy or lumpectomy) and are interested in breast reconstruction may have most of the surgery costs covered by their health insurance plan. A revision procedure may be needed at some point after reconstruction if a complication occurs or unsatisfactory results develop. Those who had insurance coverage for their cancer treatment and reconstruction procedures will also be covered for their revision procedure.

Are You Covered by Insurance for Breast Revision Surgery?

According to the Women’s Health and Cancer Rights Act of 1998 (WHCRA), all health plans that offer coverage for a mastectomy must also provide coverage for services relating to the mastectomy. This generally includes all stages of reconstruction and revision to achieve breasts with as near normal size and shape as possible, including procedures on the opposite breast to achieve a symmetrical appearance.

Breast cancer treatments and related procedures are covered by most PPO plans in the United States. PPOs will often allow patients to be seen by non-participating providers if they have the newest techniques and innovations for breast reconstruction and revision.

Determining Your Candidacy and Scheduling Surgery:

  • Find a qualified board-certified plastic surgeon.
  • Have your plastic surgeon take photographs and prepare a letter of intent.
  • Have the letter of intent sent to the insurance carrier for pre-authorization. (It may take several weeks to obtain pre-authorization and pre-determination.)  
  • After obtaining pre-authorization, schedule a surgical consultation and secondary consultation to determine your surgical strategy.  
  • Get pre-operative clearance by oncology.
    • It is important to confirm that there are no active cancer cells and that the regimen of chemotherapeutic agents will not interfere with the surgical procedure. Some medications may be temporarily withheld after surgery due to wound healing, and this should be discussed with the oncologist in full.

Surgery costs should be covered by insurance, but patients should still be aware that there will likely be co-payments and deductibles, which are necessary to be paid before the operation.

To learn more about breast revision and your insurance options, contact the office of board-certified plastic surgeon Dr. Stuart Linder by calling (310) 275-4513 or filling out our online contact form.