Will health insurance pay for breast reconstruction?


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The Women’s Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that requires group health plans and health insurance companies that offer mastectomy coverage to also pay for reconstructive surgery after mastectomy. This coverage must include all stages of reconstruction and surgery to achieve symmetry between the breasts, breast prostheses, and treatment of complications that result from the mastectomy, including lymphedema. More information about WHCRA is available from the Department of Labor and the Centers for Medicare & Medicaid Services.

Some health plans sponsored by religious organizations and some government health plans may be exempt from WHCRA. Also, WHCRA does not apply to Medicare and Medicaid. However, Medicare may cover breast reconstruction surgery as well as external breast prostheses (including a post-surgical bra) after a medically necessary mastectomy.

Medicaid benefits vary by state; a woman should contact her state Medicaid office for information on whether, and to what extent, breast reconstruction is covered.

A woman considering breast reconstruction may want to discuss costs and health insurance coverage with her doctor and insurance company before choosing to have the surgery. Some insurance companies require a second opinion before they will agree to pay for a surgery.

What type of follow-up care and rehabilitation is needed after breast reconstruction?

Any type of reconstruction increases the number of side effects a woman may experience compared with those after a mastectomy alone. A woman’s medical team will watch her closely for complications, some of which can occur months or even years after surgery (1,2,10).

Women who have either autologous tissue or implant-based reconstruction may benefit from physical therapy to improve or maintain shoulder range of motion or help them recover from weakness experienced at the site from which the donor tissue was taken, such as abdominal weakness (11,12). A physical therapist can help a woman use exercises to regain strength, adjust to new physical limitations, and figure out the safest ways to perform everyday activities.

Does breast reconstruction affect the ability to check for breast cancer recurrence?

Studies have shown that breast reconstruction does not increase the chances of breast cancer coming back or make it harder to check for recurrence with mammography (13).

Women who have one breast removed by mastectomy will still have mammograms of the other breast. Women who have had a skin-sparing mastectomy or who are at high risk of breast cancer recurrence may have mammograms of the reconstructed breast if it was reconstructed using autologous tissue. However, mammograms are generally not performed on breasts that are reconstructed with an implant after mastectomy.

A woman with a breast implant should tell the radiology technician about her implant before she has a mammogram. Special procedures may be necessary to improve the accuracy of the mammogram and to avoid damaging the implant.

What are some new developments in breast reconstruction after mastectomy?

Oncoplastic surgery. In general, women who have lumpectomy or partial mastectomy for early-stage breast cancer do not have reconstruction. However, for some of these women the surgeon may use plastic surgery techniques to reshape the breast at the time of cancer surgery. This type of breast-conserving surgery, called oncoplastic surgery, may use local tissue rearrangement, reconstruction through breast reduction surgery, or transfer of tissue flaps. Long-term outcomes of this type of surgery are comparable to those for standard breast-conserving surgery (14).

Autologous fat grafting. A newer type of breast reconstruction technique involves the transfer of fat tissue from one part of the body (usually the thighs, abdomen, or buttocks) to the reconstructed breast. The fat tissue is harvested by liposuction, washed, and liquified so that it can be injected into the area of interest. Fat grafting is mainly used to correct deformities and asymmetries that may appear after breast reconstruction. It is also sometimes used to reconstruct an entire breast. Although concern has been raised about the lack of long-term outcome studies, this technique is considered safe (1,6).

Selected References

1. Mehrara BJ, Ho AY. Breast Reconstruction. In: Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the Breast. 5th ed. Philadelphia: Wolters Kluwer Health; 2014.

2. Cordeiro PG. Breast reconstruction after surgery for breast cancer. New England Journal of Medicine 2008; 359(15):1590–1601. DOI: 10.1056/NEJMct0802899

3. Roostaeian J, Pavone L, Da Lio A, et al. Immediate placement of implants in breast reconstruction: patient selection and outcomes. Plastic and Reconstructive Surgery 2011; 127(4):1407-1416. [PubMed Abstract]

4. Petit JY, Veronesi U, Lohsiriwat V, et al. Nipple-sparing mastectomy—is it worth the risk? Nature Reviews Clinical Oncology 2011; 8(12):742–747. [PubMed Abstract]

5. Gupta A, Borgen PI. Total skin sparing (nipple sparing) mastectomy: what is the evidence? Surgical Oncology Clinics of North America 2010; 19(3):555–566. [PubMed Abstract]

6. Schmauss D, Machens HG, Harder Y. Breast reconstruction after mastectomy. Frontiers in Surgery 2016; 2:71-80. [PubMed Abstract]

7. Jordan SW, Khavanin N, Kim JY. Seroma in prosthetic breast reconstruction. Plastic and Reconstructive Surgery 2016; 137(4):1104-1116. [PubMed Abstract]

8. Gidengil CA, Predmore Z, Mattke S, van Busum K, Kim B. Breast implant-associated anaplastic large cell lymphoma: a systematic review. Plastic and Reconstructive Surgery 2015; 135(3):713-720. [PubMed Abstract]

9. U.S. Food and Drug Administration. Anaplastic Large Cell Lymphoma (ALCL). Accessed August 31, 2016.

10. D’Souza N, Darmanin G, Fedorowicz Z. Immediate versus delayed reconstruction following surgery for breast cancer. Cochrane Database of Systematic Reviews 2011; (7):CD008674. [PubMed Abstract]

11. Monteiro M. Physical therapy implications following the TRAM procedure. Physical Therapy 1997; 77(7):765-770. [PubMed Abstract]

12. McAnaw MB, Harris KW. The role of physical therapy in the rehabilitation of patients with mastectomy and breast reconstruction. Breast Disease 2002; 16:163–174. [PubMed Abstract]

13. Agarwal T, Hultman CS. Impact of radiotherapy and chemotherapy on planning and outcome of breast reconstruction. Breast Disease. 2002;16:37–42. DOI: 10.3233/BD-2002-16107

14. De La Cruz L, Blankenship SA, Chatterjee A, et al. Outcomes after oncoplastic breast-conserving surgery in breast cancer patients: A systematic literature review. Annals of Surgical Oncology 2016; 23(10):3247-3258. [PubMed Abstract]

Source: National Cancer Institute.