Below is information from Centers for Medicare and Medicaid Services (the Federal Government) web site:
The Women’s Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that provides protections to patients who choose to have breast reconstruction in connection with a mastectomy.
If WHCRA applies to you and you are receiving benefits in connection with a mastectomy and you elect breast reconstruction, coverage must be provided for:
- 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
So, that is what is supposed to happen, but I have found that health insurers try to minimize the obligations intended in the spirit of the law. Want some examples? Some insurers decline coverage for lumpectomy defects if the mass turns out to be benign instead of cancer. Some insurers decline coverage for women who delay their reconstructions more than 10 years. Some insurers decline coverage for soft tissue revisions to reconstructions several years after they have been completed. My office has encountered each of these issues on multiple occasions. Another issue is that insurance covered breast reconstruction is often unaffordable for patients who have high deductible and copays.
Under these circumstances, patients have elected to proceed with reconstruction outside of insurance. As most of my practice is cosmetic surgery that is self pay and as I have an independent Ambulatory Surgery Center, Wigod Plastic Surgery is a great alternative for surgery at a reasonable price that the large medical centers will not and actually cannot match. I already frequently provide typically insurance covered surgeries ( e.g. breast reduction, septoplasty as part of rhinoplasty, lesion removal or umbilical hernia repair as part of abdominoplasty) as self pay because it is less expensive for the patient.
As health insurance prices increase, insurers become more restrictive, and patients age, this option represents a good value and will become more common. If you think your insurance is too expensive to use or your insurance has declined coverage, call and talk over options with my office manager.
Mark D. Wigod, MD, FACS, providing Cosmetic and Reconstructive Plastic Surgery to Boise, Meridian, Treasure Valley and Southeastern Idaho.
