Insurance Coverage for Breast Reconstruction

Insurance Coverage for Breast Reconstruction

The surgeons of the Advanced Reconstructive Surgery Group are participating providers in many major insurance plans including:

  • United Health Care
  • Oxford Health Plans
  • Anthem Blue Cross Blue Shield (CT) (Dr. Erhard)
  • Cigna
  • Connecticare
  • MVP
  • The Empire Plan (NYSHIP)
  • Medicare (Dr. Erhard and Dr. Lamelas)

We are continually trying to work with other insurers to increase the number of networks in which we participate. If you are insured by a plan with which we do not participate, please know that our staff is very experienced in working with insurers to help you obtain coverage for breast reconstruction procedures.

In almost all cases, if your insurance plan provides coverage for the cost of a mastectomy it must also, according to Federal law, provide coverage for the method of breast reconstruction you wish to undergo. Coverage for reconstruction includes all methods of reconstruction, including breast implants and natural-tissue breast reconstruction options such as the DIEP, LAP, and PAP flaps. If a surgeon in your network of participating providers does not offer the method of reconstruction you prefer, your insurer must generally still provide coverage, even if this means the insurer must cover the cost of surgery with a “non-participating” physician.

We are frequently able to obtain authorizations for women who do not have access to “in-network” physicians offering the most sophisticated methods of natural-tissue perforator flap breast reconstruction to go out of their networks for surgery. We are often able to arrange for coverage, on an individual basis, for women with HMO plans, patients with self-funded ERISA plans, people who have previously been denied coverage for breast reconstruction surgery and for women with unsatisfactory outcomes from prior reconstruction. In all cases, we will work closely with you and your insurance carrier to minimize any out-of-pocket expenses.

For more information, please contact our office at 203-863-0003.

Overview of Federal Law Pertaining to Breast Reconstruction

A more comprehensive description of State and Federal laws pertaining to breast reconstruction surgery can be found in the Your Rights section of this site.

The Women’s Health and Cancer Rights Act (WHCRA) of 1998 contains important protections for women who wish to have breast reconstruction after mastectomy. This law requires group health plans and individual health policies that provide coverage for mastectomies to also provide coverage for breast reconstruction.

In accordance with the WHCRA, members of group health plans receiving mastectomy-related services are entitled to:

  • Reconstruction of the breast on which the mastectomy has been performed
  • Surgery on the opposite breast to produce a symmetrical appearance (including reduction, breast lift or augmentation)
  • Treatment of physical complications at all stages of the mastectomy, including lymphedema

Additional information is available from the US Department of Labor, which has oversight of the WHCRA.

» Contact us if you would like more information or to schedule a consultation