Will Insurance Cover Implant Exchange under Cancer Mastectomy Reconstruction? Is Procedure Realistic?

Hello! Thank you for your question! While authorization is still necessary for any surgical procedure, typically this can be done in order to provide symmetry for you. In 1998, the Women's Health Rights & Cancer Act was passed which mandates insurance coverage for surgical treatment and breast reconstruction on the affected breast as well as a contralateral symmetry procedure. Discuss your desire for symmetry with your reconstructive surgeon. Best wishes and congratulations on your success thus far!

Insurance should cover your continued reconstructive surgery following mastectomy.

Women's Rights for Breast Reconstruction  Following Mastectomy

The Federal Women's Health and Cancer Rights Act of 1998 is still the law today

Under the federal Women's Health and Cancer Rights Act of 1998, a yearly notification
of your benefits pertaining to breast reconstruction must be sent to you by your insurance company.
The Women's Health Care Act states that benefits must be provided for:
• Reconstruction of a surgically removed breast
• Surgery and reconstrcution of the other breast to produce a symmetrical appearance
• Prostheses and treatment for physical complications from all stages of a mastectomy, including lymphedema

These benefits are subject to the conditions and terms of your plan, including maximum benefit amounts, deductibles,
copayments, and coinsurance provisions. The benefits are subject to your plan's exclusions and limitations.

By federal law, your insurance company is required to cover anything related to your breasts once you are diagnosed with breast cancer, including implant changes.  As long as your surgeon includes the history of breast cancer in the diagnosis, then they should cover it.  The silicone implants are much more natural feeling, and when you are feeling nothing but some skin, thin muscle, and implant, you want it to feel as natural as possible.  I hope this helps.

Yes it should be covered.  If the device has fold or wrinkles it will eventually have problems.  Patients with thin skin envelopes over implant have different options with the newly release shaped implants by Sientra.  You can use all sorts of biologic material such as alloderm.  You can also have fat grafting.  If none of these options work you can have the implants removed and replaced with your own tissue like the DIEP flap.

In theory all surgery related to breast reconstruction should be covered in separate state legislation (approx 13 states) and more recently by Federal legislation.  Having said that the climate for insurance reimbursement is becoming less predictable.  The key in a case such as yours is to have your surgeon precertify the surgery after providing clear documentation of the indications for your procedures.

In answer to how realistic is it to do an exam would be essential to determine that.