Thinking about cancer or dealing with cancer risk can be scary or overwhelming, but we believe that receiving information and resources is comforting, empowering, and lifesaving.
The Women’s Health and Cancer Rights Act (WHCRA) took effect in 1998. This federal law requires most employer and group health plans that pay for mastectomy to also pay for:
Despite the law, your initial request for reconstruction may be denied. If you belong to a managed care plan, your insurer will most likely approve your request for in-network procedures (with surgeons already contracted by the insurance company). You’ll have to make a very compelling case for why you want to go out-of-network: Maybe you prefer direct-to-implant reconstruction, but the surgeons in your network or area only do traditional, expansion-to-implant reconstruction. Perhaps you’re very thin and lack enough abdominal tissue to rebuild your breasts, but your local surgeons do not perform other flaps from the hips, thighs or buttocks.
Your insurance company won’t cover procedures it considers “medically unnecessary.” Some insurers routinely deny requests for prophylactic mastectomy, considering it to be medically unnecessary, even for high-risk women. Denials may occur when women decide to remove both healthy breasts to reduce their breast cancer risk, or when they are having unilateral mastectomy to treat breast cancer and want to have the opposite healthy breast also removed because of their high hereditary risk for another breast cancer. If your request for prophylactic mastectomy and reconstruction is denied, ask your primary care physician, oncologist, and medical geneticist to write supportive letters explaining your high-risk status. Management of hereditary breast cancer risk has evolved and more insurers understand preventative mastectomies reduce risk as well as potential future costs of treating the disease, but some denials still occur.
To learn more about the WHCRA, contact the Department of Labor, Pensions, and Welfare Benefits Administration, 800-998-7542 or visit their website. Many states also have additional laws regarding reconstruction. Contact your state’s Department of Health or Insurance Commissioner for information.
FORCE also has sample insurance appeal letters to help people denied coverage of services needed to manage cancer risk or treat cancer.