Written or reviewed by David Bogue, MD, board-certified plastic surgeon.
In many cases, yes. Under the Women’s Health and Cancer Rights Act of 1998 (WHCRA), applicable health plans that cover mastectomy must also cover surgery and reconstruction of the opposite breast when it is performed to create a more symmetrical appearance. Coverage can still be subject to the plan’s deductible, coinsurance, network, documentation, and prior-authorization requirements.
When only one breast is reconstructed, the natural breast may differ in size, shape, position, or nipple height. Surgery on that breast may therefore be considered part of breast reconstruction rather than an unrelated cosmetic procedure.
What Does WHCRA Require Health Plans to Cover?
For an individual receiving covered benefits in connection with a mastectomy who elects breast reconstruction, WHCRA requires applicable plans to provide coverage for:
- all stages of reconstruction of the breast on which the mastectomy was performed;
- surgery and reconstruction of the other breast to produce a symmetrical appearance;
- breast prostheses; and
- treatment of physical complications of the mastectomy, including lymphedema.
The reconstructive plan is determined in consultation with the patient and attending physician. The U.S. Department of Labor’s WHCRA guidance provides additional information about these protections.
Which Procedures May Be Covered on the Opposite Breast?
The appropriate procedure depends on the reconstructed breast and the patient’s anatomy. Surgery on the opposite breast may include:
- a breast lift to improve breast and nipple position;
- a breast reduction to reduce volume and improve shape;
- a breast augmentation to add volume; or
- a combination of reshaping techniques when needed for balance.
Perfect symmetry cannot be guaranteed. The goal is to create the best reasonable balance between breasts that may differ in tissue, scars, radiation exposure, and response to surgery.
Does Coverage Mean the Surgery Has No Out-of-Pocket Cost?
No. WHCRA permits deductibles and coinsurance when they are consistent with the cost-sharing requirements used for other medical and surgical benefits under the plan. Network status, benefit limits, and authorization procedures may also affect what a patient owes.
Before surgery, the office can help verify benefits and submit documentation when authorization is required. Patients should also contact their plan directly and ask for a written explanation of benefits, network rules, deductible, coinsurance, and authorization requirements.
Is Approval Automatic?
Coverage rights do not eliminate the insurer’s administrative process. A plan may request medical records, photographs, procedure codes, a treatment plan, or documentation explaining why surgery on the opposite breast is needed for symmetry.
An initial denial does not necessarily mean the benefit is excluded. The denial notice should explain the reason and available appeal process. Questions about an individual policy should be directed to the plan administrator or insurer because benefits vary.
Does WHCRA Apply When a Mastectomy Is Not Related to Cancer?
WHCRA is not limited to breast-cancer diagnoses. According to federal guidance, its protections may apply when a covered mastectomy is performed for another medical reason. The key questions are whether the plan is subject to WHCRA, whether it covers the mastectomy, and whether the patient elects reconstruction in connection with it.
What About Surgery After a Lumpectomy?
WHCRA specifically addresses benefits connected with mastectomy. Coverage for reconstruction or symmetry surgery after lumpectomy may depend on medical necessity, the terms of the individual plan, and applicable state requirements. The office can review the proposed operation and determine what information should be submitted to the insurer.
Can Opposite-Breast Surgery Be Performed at a Later Operation?
Yes. Symmetry surgery may be performed during the initial reconstruction or later, after the reconstructed breast has healed and its shape has become more predictable. Radiation, staged reconstruction, tissue expansion, and revision procedures can all influence timing.
Dr. Bogue coordinates the plan around cancer treatment, reconstruction technique, healing, and the changes most likely to improve balance.
Dr. Bogue Explains Opposite-Breast Coverage
Discuss breast reconstruction and symmetry with Dr. Bogue in Boca Raton.
Call 561-886-1000 or contact the office online. The office can review the proposed surgical plan and help determine which insurance requirements may apply.