Does Insurance Cover Fat Grafting to Improve Implants Post-breast Cancer?

Question

Had exchange surgery three weeks ago and implants can be seen due to thin skin. My PS suggested fat grafting to improve look and contour. Does insurance cover this procedure? I would love to have this procedure, but cannot pay the high costs associated with process. Thank you, rrhann

Larry S. Nichter, MD, MS, FACS · Answer

Theoretically your insurance is required to cover all breast reconstruction required following breast cancer surgery. The problem is that fat grafting is a new technique and may be considered "experimental" by your insurance company. A strong letter of necessity with pre-authorization from the company is suggested. 

	Here are the facts of the current federal law:

	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.

Ron Shelton, MD · Answer

Make sure that the doctor who will follow you for the breast cancer agrees  that you can have fat injections as some controversey exists about its safety in the breast.If your doctor clears it, you could have the plastic surgeon write a letter of medical necessity requesting preapproval to the medical director of the insurance carrier and see what response you receive.

Peter A. Aldea, MD · Answer

Breast Reconstruction has changed significantly in the past 10 years but insurance company reimbursement has not.

	Let's leave aside the potential merits of fat grafting in a reconstructed breasts and potential trade offs. Assuming your contract with your insurance company does have coverage for Breast Reconstruction (after all they did pay for breast reconstruction and ?expander/?implant exchange), this does not mean that they will pay for every procedure on the market. If the procedure does not have a CPT code that they accept, it will not be covered as they will call it "experimental".

	Every insurance company is different and issues different policies. The fact that your Plastic surgeon did NOT suggest to you that your insurance will pay for it suggests to me that they do not pay for it. You may want to call them yourself and see.

	Dr. Aldea

Alan M. Engler, MD, FACS (retired) · Answer

"Coverage" is a difficult word to define.  Of course, post-mastectomy reconstruction is and should be a "covered" procedure but that doesn't mean that you can (necessarily) go to any surgeon you want and have the surgery paid-for.  You have to work with your insurance company to find such a surgeon.

	Fat grafting is a relatively new procedure and, as such, there may be some resistance to having the procedure "covered."  Your best bet is to work with your plastic surgeon to have him or her contact your insurance company on your behalf (you can do it, too, but you may then have to convince a surgeon to do the procedure which will require him or her to get consent on their own) and find out exactly which procedure(s) are covered, and what the payments would be for that.

	I hope that this helps and good luck,

	Dr. E

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