Will Insurance Pay for Breast Reduction After Lumpectomy?

Question

I am 43 years old and was diagnosed with breast cancer in August of 2008. I had a lumpectomy on my left breast and underwent 6 months of chemo and 30 rounds of radiation. I have had clean checkups for 3 years and am feeling great. I would like to have my right breast (which is at least 2 cup sizes bigger) reduced. I also have double coverage through BCBS. Will insurance pay for this type symmetry reduction?

Lewis Albert Andres, MD · Answer

Hello! Thank you for your question! Contour deformities or asymmetry between size/shape of the other breast following lumpectomy and radiation may occur after everything settles and is not an uncommon scenario following lumpectomy.  There are several options to ameliorate this and you should discuss your options with your plastic surgeon to determine which option would be best for you. It is recommended to wait approximately 6 months to one year after your radiation therapy is completed before considering any reconstructive procedure on the breast.Typically, implants in the setting of an irradiated breast has higher rates of complication, including infection, wound complications, capsular contracture, etc. Many surgeons, including myself, have placed implants to improve symmetry in these instances with excellent results. However, if your deformity is a contour issue with a soft tissue deficiency, placing an implant beneath the breast may actually worsen the deformity as it is not addressing the issue to "fill" the defect. For such problems, it may be a wiser decision to consider fat grafting for smaller defects, where fat is harvested for another area of your body and then reinjected into the defect, thus adding volume as well as having the added properties of fat graft stem cells. Autologous flaps such as local tissue, TAP, or LDMF may be needed for larger soft tissue defects.  Of course, reduction of the other breast to create symmetry is an option, or a combination of procedures on both breasts.  Reduction is a great method to achieve symmetry and improve appearance. Insurance typically should cover this with your history of breast cancer. Best wishes!

Robert Stroup, Jr., MD, FACS · Answer

Health insurance companies (including BCBS) are required, by federal law, to cover any procedure done to "restore symmetry" after a patient has surgery for treatment of breast cancer. So you should have no trouble getting coverage. All that is left to do is to see a board-certified plastic surgeon for a consultation and have him/her submit the appropriate documentation to you insurance company.

Robert L. Kraft, MD, FACS · Answer

Every insurance company has its own criteria and BCBS criteria differ from state to state.  However, generally, correction of an asymmetry which results from treatment for breast cancer will be covered pursuant to federal law.  It is important for your plastic surgeon to obtain a pre certification and in that process to report to the insurance company your history of breast cancer treatment.

Tom J. Pousti, MD · Answer

Thank you for your question.

	Insurance companies are more difficult to work with and each one has it's own criteria for what they will or will not cover.  The first step would be to visit with a surgeon who could help you achieve your goals and see if he/she accepts insurance for this type of surgery.  The doctor would then send paperwork trying to get authorization for the surgery.

	In my practice, I send a letter as well as patient photos and any supporting documentation as to why this surgery should be covered by insurance.

	Best Wishes.

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

Probably.  Insurance companies are required to provide surgical procedures to correct asymmetry resulting from breast cancer surgery and treatment, so there's a good chance this will be "covered."  Of course, what the insurance company indicates is appropriate payment for the surgery may not be the same as what your surgeon feels is adequate, so you'll need to find a surgeon who participates in your insurance plan, or who will accept their allotment as payment, and then work with him or her to authorize your procedure according to the stipulations of your policy.  Based on what you say, I think that your procedure will be covered.

	I hope that this helps and good luck,

	Dr. E

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