Did You Know That Most Health Insurers Are Required To Pay For Breast Reconstruction Surgery?

Many breast cancer patients who have a mastectomy may elect for a reconstruction surgery at the time of the mastectomy or chose to wait. Either way women usually chose to have reconstruction to restore a sense of self, or simply get back to they way they used to look.

The choice is extremely personal, and the surgical options available give a very real and authentic look of breasts.

What Are My Coverage Options?

The WHCRA applies to most patients receiving benefits in connection with a mastectomy. Your health plan or insurance issuer (or your health insurance company) is likely required “to provide you with a notice of your rights under WHCRA when you enroll in the health plan, and then once each year,” according to the U.S. Department of Labor. The following procedures must be covered:

• All stages of reconstruction of the breast on which the mastectomy has been performed
• Surgery and reconstruction of the other breast to produce a symmetrical appearance
• Prostheses and treatment of physical complications of all stages of the mastectomy, including lymphedema (a condition where swelling in an arm or leg is caused by a lymphatic system blockage)

“Group health plans can either be ‘insured’ plans that purchase health insurance from a health insurance issuer, or ‘self-funded’ plans that pay for coverage directly.  How they are regulated depends on whether they are sponsored by private employers, or state or local (‘non-federal’) governmental employers,” said the Centers for Medicare & Medicaid Services (CMS).

“Private group health plans are regulated by the Department of Labor.  State and local governmental plans, for purposes of WHCRA, are regulated by CMS.  If any group health plan buys insurance, the insurance itself is regulated by the State's insurance department,” CMS continued.

Please contact your employer’s administrator find out if your group coverage is insured or self-funded, and to determine what entity or entities regulate your benefits. CMS notes health insurance sold to individuals (not through employment) is primarily regulated by State insurance departments.

Any sum of money caused by the unexpected diagnosis of a harrowing disease can cause immense stress, but individual costs varied greatly depending upon treatment intensity and duration, survival rates and the stage of the cancer.

According to the Journal of the National Cancer Institute report, out-of-pocket costs in 2019 were the highest for breast ($3.14 billion), prostate ($2.26 billion), colon ($1.46 billion) and lung ($1.35 billion) cancer patients a reflection of the higher rates of these cancers.

Paying for Cancer Find Someone Who Will Advocate For You

Choosing Your Reconstruction

When a woman is faced with reconstructive surgery after undergoing a mastectomy it is overwhelming. So let’s break down some of the options below.

The first option uses your own tissue and is performed at the same time as the mastectomy. This approach involves taking the tissue from your lower abdomen and implanting it into your chest.

Dr. Andrea Pusic, the chief of Plastic and Reconstructive Surgery at Brigham Health, explains that new connections for blood flow are devised and the end result is quite natural.

“The lower abdomen will have a scar from hip to hip, it's much like a tummy tuck only the fat removed has now been formed into a mound to create the new breast. This is a long (eight hour) surgery, and the hospital stay is three to five days. You will leave the hospital with drains and will need at-home care until the drains are removed. If you are having radiation, this surgery is probably not available as the skin has to be in good condition. It would be done after you have healed,” said Dr. Pusic.

The second option is breast implants. This option can also be done at the time of the mastectomy surgery or later on. If you've elected to have implant reconstruction following a mastectomy, there are two options for the procedure: using a breast tissue expander which is a two-step process, or direct-to-implant reconstruction which is completed at the same time as the mastectomy.

Implant Reconstruction After a Mastectomy: The Options

Dr. Pusic explains, with the tissue expander implant reconstruction, an expander is put in between the skin and chest muscle at the same time as the mastectomy surgery or afterwards, if you're choosing delayed reconstruction. The expander has a small valve that will be filled gradually over time with saline every one to two weeks, stretching the skin until the area is ready for the permanent implant.

“Only a minority of women are great candidates for direct-to-implant reconstruction, says Dr. Pusic, that's because it's best for women with small breasts and/or women who are having no skin removed and preserving the nipple and areola. Women who are able to get this option can go home from a mastectomy with their breast reconstructed.”

Restoring Your Sense Of Self

No matter what type of reconstruction surgery you have the main goal is to get you back to feeling like yourself again. Which is what Marnie Rustemeyer, who left Wall Street to become a nipple tattoo artist, has dedicated her life helping women after breast reconstruction.

Tattooing nipples onto reconstructed breasts after surgery has become increasingly popular for the population of women getting mastectomies for breast cancer.

Feeling Whole Again The Increasing Popularity Of Nipple Tattoos After Breast Cancer Surgery

Rustemeyer is a thyroid cancer survivor and breast cancer pre-vivor herself. Her work allows her to give back to women who are just looking to feel whole again.

"In August of 2013 I was diagnosed with the BRCA gene or breast cancer gene mutation," Marnie told SurvivorNet. "I chose to have both my breasts and my ovaries removed." After her mastectomy, she gave up a career on Wall Street and went into medical tattooing.

 

With assistance from Abigail Seaberg

Learn more about SurvivorNet's rigorous medical review process.

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