Paying for Breast Reconstruction and Revision Surgery

If you are thinking about breast reconstruction surgery following a lumpectomy or mastectomy, you may have questions about the cost.

Your total bill for breast reconstruction or revision (also called corrective) surgery will depend a lot on the type of health insurance you have and whether the plastic surgeon and surgery facility you choose is within your health plan’s network.

Here’s what you need to know about navigating insurance coverage for breast reconstruction and minimizing your out-of-pocket expenses.

Many but not all health insurance plans in the United States cover breast reconstruction after mastectomy. Contact your insurer to find out the specifics of coverage under your plan.

In the United States, a federal law called the Women's Health and Cancer Rights Act (WHCRA) of 1998 requires group health insurance plans that pay for mastectomy to also cover breast reconstruction. This can include procedures that may be needed over time to refine the reconstructed breast(s). Reconstruction procedures are covered by insurance regardless of whether they are done at the same time as a mastectomy or lumpectomy or take place months or years later. 

Although the law doesn’t specifically mention reconstruction after lumpectomy (just mastectomy), it is generally interpreted as requiring group health insurance plans to cover reconstruction after lumpectomy.

Some types of group health insurance plans are exempt from the WHCRA, including some government health plans and health plans offered by some religious organizations. The WHCRA also doesn’t apply to Medicare and Medicaid.

Many states have passed additional laws requiring health insurance companies to cover breast reconstruction after mastectomy.

Medicare usually covers breast reconstruction after a mastectomy if your surgeon determines the procedure to be medically necessary. In some cases, Medicare may require that you finish certain breast cancer treatment before agreeing to cover reconstruction surgery. If you have Medicare, it might be helpful for you or someone close to you to check in with your plastic surgeon’s office to ensure that all medical documents showing the procedure is medically necessary are submitted for approval.

Medicaid coverage of breast reconstruction surgery varies by state. Contact your state Medicaid program to find out more.

VA health care and TRICARE plans cover breast reconstruction surgery after a mastectomy.

These tips can help you get as much of your costs covered by insurance as possible.  

Health insurance coverage can be confusing. To cut some of the guesswork out of what’s covered and why, consider a call to your health insurance company before you schedule your surgery. Ask whether your plan covers breast reconstruction and, if so, what its criteria for covering breast reconstruction are. Knowing these criteria will help you to ensure that your surgeon’s office is providing the needed documents to your insurance company. Ask if you need to get prior authorization from the insurance company for the surgery to be covered.

Also, ask your insurance company and plastic surgeon about out-of-pocket expenses you might incur from the surgery. Even if your insurance covers breast reconstruction, you will usually still need to pay deductibles, copays, coinsurance, and/or other fees. It can sometimes be challenging to determine the exact costs of a breast reconstruction surgery, but your health insurance company and plastic surgeon should be able to provide some guidance on how the billing of such procedures works.

Check whether the plastic surgeon you’re interested in working with is “in-network” for your insurance. Providers are considered to be in-network if they have negotiated contracts with your health insurance company.

If breast reconstruction is covered under your health plan and you schedule a surgery with an in-network surgeon, you will typically only be responsible for paying the deductible, copays, and coinsurance fees your plan requires. If the surgeon you want to work with is out of network, the insurance company may still pay part of the bill if your plan has out-of-network benefits.

“Particularly when a patient is coming to us from out of state to get a specialized procedure that is not available in their community — like DIEP flap reconstruction or a revision procedure — we can in some cases convince the insurance company to cover the procedure even when we’re not in-network for that plan,” says Ron Israeli, MD, FACS, a plastic surgeon at New York Breast Reconstruction and Aesthetic Plastic Surgery in Great Neck, NY. 

Some practices have people on staff (sometimes called financial navigators or practice administrators) who are very knowledgeable about health insurance and can help you with requests from your insurance company. These might include pre-authorization (sometimes called pre-approval or pre-certification) for your surgery or appealing denials of coverage. If you are deciding between two surgeons, you might choose to work with the one that has staff prepared to answer your insurance questions and work directly with your insurance company to get as many of your costs covered as possible, if that’s an option.

One reason to consider immediate reconstruction, if you’re a candidate for it, is that you may need fewer overall surgeries (and less time off from work) to complete your reconstruction.

Planning for your initial reconstruction and for follow-up procedures to be done in the same year may also mean you only have to pay your full out-of-pocket maximum (the limit on how much your health insurance plan expects you to pay out-of-pocket for healthcare services that are covered) one year, rather than multiple years in a row. The amount you contribute toward your out-of-pocket maximum resets (returns to zero) every time your health plan renews (for example, each January) or you switch to a new plan.

Revision (also called corrective) breast reconstruction procedures are done to fix problems that can develop after a mastectomy or reconstruction surgery, such as pain, scarring, asymmetry, or breast implant displacement or rupture. 

As with coverage of reconstruction after a mastectomy, most but not all health insurance plans cover corrective breast reconstruction. The Women’s Health and Cancer Rights Act (WHCRA) of 1998 requires group health plans to pay for follow-up procedures, including ones that are done years after a mastectomy. However, what’s covered under individual plans may vary, and not all types of health insurance plans are subject to the WHCRA. 

You may need to work with your plastic surgeon’s office to provide documentation to your health insurance company that the surgery is medically necessary and not just cosmetic.

When you meet with a plastic surgeon for a consultation, be sure to tell them all the reasons you’re seeking corrective surgery. Make a list of the problems you’ve been having with physical function and quality of life, advises Dhivya Srinivasa, MD, a plastic surgeon at Cedars-Sinai Medical Center in Los Angeles who specializes in breast reconstruction. “Do you have issues with range of motion, pain, or tightness? Has the appearance of your reconstruction changed? Is your appearance causing emotional distress or depression or serving as a daily reminder of your cancer? These are all things your surgeon needs to know,” she says. 

Having a clear picture of your situation can help your plastic surgeon make the case to the insurance company to cover the procedure(s).

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  Is breast reconstruction or corrective reconstruction covered by my insurance plan?

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  Am I limited to in-network surgeons and services for this surgery?

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  If I meet with multiple plastic surgeons to discuss options for reconstruction, are these appointments covered?

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  If I choose to use a plastic surgeon who specializes in a particular technique not available within my insurance plan’s network, are expenses still covered?

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  How might my coverage change if I need to travel out of state for care?

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  What out-of-pocket costs (for example, deductibles and copays) will I be charged for surgery with an in-network plastic surgeon? What about for surgery with a plastic surgeon who is out of network?

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  Are the other healthcare professionals involved in my surgery (for example, anesthesiologists) in-network?

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  Is my hospital stay covered? If so, for how many days?

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  Is there a limit to the amount of coverage provided?

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  What does my surgeon’s office need to do for you to approve the coverage of (pre-authorize) my surgery?

Read more questions to ask your surgeon, health insurance company, and financial navigator about paying for surgeries related to breast cancer.

If you’re uninsured, underinsured, or otherwise having trouble covering the cost of breast reconstruction or corrective reconstruction, here are some ways to make costs more manageable.  

There may be more options for getting covered (or improving your coverage) than you think. If your income is low, you may be eligible for plans that are free. Learn more about options for health insurance coverage. You can get free help comparing the health insurance plans you’re eligible for from a financial navigator or social worker at your hospital or cancer center. There are also nonprofits that will assist you in understanding your health insurance options, such as Triage Cancer.   

If you’re thinking of getting breast reconstruction or corrective reconstruction at a particular hospital or cancer center, reach out to their financial assistance department (this department might also be called financial counseling, charity care, or it may just be the billing department). They may be able to offer you an interest-free payment plan or, if you meet eligibility requirements, provide you with free or discounted medical services. 

Some organizations offer needs-based assistance with breast reconstruction or corrective surgery costs, such as Mission Plasticos’ Reshaping Lives America program, My Hope Chest, AiRS, and Breastoration. Others offer assistance with transportation or lodging expenses, should you need to travel for your surgery. For instance, the American Cancer Society’s Hope Lodge program provides free lodging for eligible people traveling to more than 30 locations in the U.S. for treatment and the Air Care Alliance arranges free flights for people traveling for medical care. You can also ask the staff at your plastic surgeon’s office or a social worker or nurse navigator at the hospital where you’ll be getting surgery to help connect you with other resources to reduce your costs.