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

I Had Dbl Mastectomy W/ Reconstruction (Saline Implants). My Left Breast Has Always Had a Couple of Wrinkles/ Bubbles. I would like to exchange my implants for silicone. (I am now seeing some significant dimpling etc. in my left breast,not there before). Would my insurance be required to pay for this under cancer mastectomy reconstruction? How realistic is this to do? Thank you.

Doctor Answers 10

Will insurance cover implant exchange under cancer mastectomy reconstruction? Is procedure realistic?

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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!

Scottsdale Plastic Surgeon
5.0 out of 5 stars 28 reviews

Insurance coverage of breast reconstruction following mastectomy

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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.

Breast reconstruction, nipple reconstruction, breast cancer, DCIS, mastectomy, TUG flap, DIEP flap, Latissimus flap, fat graft i

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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.

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Breast Reconstruction

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The Women's Health and Cancer Rights Act (WHCRA) of 1998 is a federal law that that requires health insurance companies and self-insured group health plans that cover mastectomies to also provide benefits for mastectomy-related services, including breast reconstruction surgery. WHCRA is also known as Janet's Law, named after Janet Franquet, who was denied reconstructive surgery after a mastectomy in 1997.
If you're receiving health insurance benefits in connection with a mastectomy and you elect breast reconstruction surgery, WHCRA states that the insurer also must cover:

•Reconstruction of the breast on which the mastectomy was performed
•Surgery and reconstruction of the other breast to create a symmetrical appearance
•Prostheses (breast implants)
•Treatment for physical complications of the mastectomy, including lymphedema (swelling caused by an accumulation of lymph fluid in the arm)

According to the Department of Health and Human Services, WHCRA applies to three types of health insurance coverage:

  • Self-funded group plans
  • Fully insured group plans 
  • Individual health insurance plans 

Also, keep in mind that some state laws provide more protections than WHCRA. To learn more, contact your state's insurance department. Best wishes!

Christine Sullivan, MD
Columbus Plastic Surgeon
4.5 out of 5 stars 35 reviews

Secondary breast reconstruction and insurance coverage

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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.

Jay W. Birnbaum, MD
New York Plastic Surgeon

Implant exchange for breast cancer

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If you are having implant problems after you had breast reconstruction for cancer, then it should be covered.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Implant Exchange Coverage in Breast Cancer Patient

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This procedure should be covered by your insurance carrier according to federal law.   You will see improvement in the wrinkling and dimpling with silicone implant exchange, but not complete resolution.   Fat grafting is gaining acceptance as an adjunct to implant breast reconstruction to give a softer more natural look.   I wish you a safe and healthy recovery.

Paul S. Gill, MD
Houston Plastic Surgeon
4.8 out of 5 stars 94 reviews

Insurance Coverage for Breast Cancer Reconstruction

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Your implant exchange should be covered by your insurance.   Of course, you need to ultimately check with your insurance carrier.  But given your history of breast cancer/mastectomy, it has been my experience that patients get this procedure covered by their insurance.

Breast Reconstruction implant replacement

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A federal mandate in 1996 established coverage for breast cancer patients for surgeries related to their breast reconstruction as well as symmetry operations on the contralateral/uninvolved breast. An implant exchange should be covered, but I always recommend that patients contact their insurance provider to verify within their own plan. Changing from saline to silicone implants will provide a much different feel to the implant. It is also likely to improve your complaints of wrinkling and "bubbles." However, these are unlikely to go away entirely due to the lack of tissue between your skin and the implants.

David Bogue, MD
Boca Raton Plastic Surgeon
5.0 out of 5 stars 26 reviews

Insurance SHOULD Cover Implant Change Post-Mastectomy

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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.

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.