Breast reconstruction coverage details
The Women’s Health and Cancer Rights Act (WHRCA) requires most group health insurers to cover of all stages of breast reconstruction following a mastectomy or lumpectomy including, but not limited to:
- Breast implants
- Acellular dermal matrix products
- Flap reconstruction
- Nipple/areolar reconstruction and tattooing
- Surgery for symmetry of the contralateral (opposite) breast
- Revision of previously reconstructed breast
Breast reconstruction surgery may be done at the same time as a mastectomy or at a later time. Insurance coverage cannot be denied based on the period of time between the mastectomy and the request for reconstructive surgery. Similarly, breast reconstruction or revisions cannot be denied because you had a different insurance plan at the time of the mastectomy; or because the mastectomy was not due to a cancer diagnosis. Despite the title, nothing in the WHCRA limits the benefit to patients with cancer.
Many insurers will cover mastopexy or breast reduction and lift to preserve the viability of the nipple in preparation for a nipple-sparing mastectomy.
While most health insurers will cover breast implant removal and replacement if complications occur in a patient who had a mastectomy and breast reconstruction. It's important to note that many breast implant manufacturers have warranties on their products which will cover replacement of a ruptured implant (and possibly the implant on the opposite side) plus financial assistance toward related surgical fees.
WHRCA does not require 100% coverage by health insurance so copays, coinsurance and deductibles may apply. Some group health insurers limit coverage to in-network providers or use a less-favorable reimbursement formula for out-of-network providers.
Medicare & Medicaid
Medicare and Medicaid are public programs that are not bound by the WHRCA. They have their own rules. Medicare covers breast reconstruction after a "medically necessary" mastectomy typically associated with a cancer diagnosis, while Medicaid coverage varies by state.
See the Insurance & Paying for Care section of our website for more information.