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Achieving balanced breasts through reconstruction

The Women’s Health and Cancer Rights Act (WHRCA) requires that most group health plans cover all stages of reconstruction of the breast(s) on which a mastectomy was performed. It also stipulates coverage of surgery and reconstruction of the other breast to produce a symmetrical or balanced appearance. 

Surgery on a breast without cancer to establish symmetry with the opposite breast is considered medically necessary when it is related to breast reconstruction following a mastectomy. Methods to create breasts of similar size and shape may include:

  • Breast reduction (reduction mammoplasty) 
  • Breast lift (mastopexy)
  • Enhancement with a breast implant
  • Autologous tissue reconstruction (e.g. DIEP, TRAM, SIEA, or Latissimus dorsi flap)
  • Fat grafting

Some health insurers consider fat transfer or grafting experimental and refuse coverage of this technique. However, the American Society of Plastic Surgeons states, “Autologous fat grafting should [not] be considered experimental but should be regarded as part of reconstructive surgery when it is performed to approximate a normal appearance of the breasts following mastectomy or lumpectomy.”

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.

paying-for-service
  • Alliance in Reconstructive Surgery (AiRS) Foundation provides grants to offset the costs of breast reconstructive surgery for women in need.
  • If your insurance company denies coverage of care related to your breast reconstruction following mastectomy, visit the Health Insurance Appeals section of our website for guidance and resources.
  • Medicare Rights Center is a national nonprofit organization that works to ensure access to affordable health care for older adults and people with disabilities under the Medicare program.
  • Patient Advocate Foundation provides case managers who help identify financial assistance programs and resources for those facing challenges.