Many women who have a mastectomy — surgery to remove an entire breast to treat or prevent breast cancer — have the option of having the shape of the removed breast rebuilt. “As laws are in place governing insurance company requirements with respect to breast cancer patients, it’s important for patients to know their rights,” said Staten Island-based Michael J. Lacqua, M.D., a plastic surgeon and board certified wound care physician experienced in reconstructive breast surgery.
With patient advocacy in mind, the New York City surgeon is sharing the following information:
The Women’s Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that requires group health plans and health insurance companies that offer mastectomy coverage to also pay for reconstructive surgery after mastectomy.
This coverage must include all stages of reconstruction and surgery to achieve symmetry between the breasts, breast prostheses, and treatment of complications that result from the mastectomy, including lymphedema.
Some health plans sponsored by religious organizations and some government health plans may be exempt from WHCRA. Also, WHCRA does not apply to Medicare and Medicaid. However, Medicare may cover breast reconstruction surgery as well as external breast prostheses (including a post-surgical bra) after a medically necessary mastectomy.
NEW YORK STATE LAW
Medicaid benefits vary by state; a woman should contact her state Medicaid office for information on whether, and to what extent, breast reconstruction is covered.
In New York State, insurers are required by law to cover surgery for women diagnosed with breast cancer, which among a host of surgeries incudes reconstruction – the rebuilding one or both breasts.
However, self-insured health plans and plans paid for by employers outside of New York State are not required to pay for breast reconstruction. If you have questions about the breast reconstruction law or other insurance laws, call the New York State Department of Financial Services at 1-800-342-3736. mastectomy
A woman considering breast reconstruction may want to discuss costs and health insurance coverage with her doctor and insurance company before choosing to have the surgery. Some insurance companies require a second opinion before they will agree to pay for a surgery.
RECONSTRUCTIVE SURGERY OPTIONS
Women who choose to have their breasts rebuilt have several options for how it can be done.
Breasts can be rebuilt using implants (saline or silicone). They can also be rebuilt using autologous tissue (that is, tissue from elsewhere in the body). Sometimes both implants and autologous tissue are used to rebuild the breast.
Surgery to reconstruct the breasts can be done (or started) at the time of the mastectomy (which is called immediate reconstruction) or it can be done after the mastectomy incisions have healed and breast cancer therapy has been completed (which is called delayed reconstruction). Delayed reconstruction can happen months or even years after the mastectomy.
In a final stage of breast reconstruction, a nipple and areola may be re-created on the reconstructed breast, if these were not preserved during the mastectomy.
Sometimes breast reconstruction surgery includes surgery on the other, or contralateral, breast so that the two breasts will match in size and shape. New York State requires health insurance policies that provide medical and surgical coverage to pay for reconstruction and for surgery to the other breast to make sure the breasts match.
Sources: Office on Women’s Health, U.S. Department of Health & Human Services; U.S. Centers for Medicare & Medicaid Services; New York State Department of Health
To find out more about breast reconstruction surgery, contact the Staten Island or Brooklyn offices of Michael J. Lacqua, M.D., to schedule a consultation:
24-Hour Telephone: 718-761-3700
Dr. Lacqua’s offices are located at:
- 2372 Victory Boulevard
Staten Island, NY 10314
- 9602 4th Avenue
Brooklyn, NY 11209
On the Web: www.drmichaeljlacqua.com
Twitter: www.twitter.com/DrLacqua (@drlacqua)