Getting insurance to cover any surgical procedure can be challenging. However, many insurance companies are required by law to cover breast reconstruction surgery and certain post-mastectomy products needed after breast cancer surgery.
Discover what insurance companies must cover after your mastectomy, what they sometimes cover, and what they deem unnecessary.
What Is Covered Under WHCRA Law?
The Women’s Health and Cancer Rights Act (WHCRA) was signed into law in 1998 to protect women with breast cancer who choose to undergo breast reconstruction following a mastectomy.
This federal law requires most insurance plans, group health plans, and HMOs covering the mastectomy procedure to provide reconstructive breast surgery coverage. If complications arise at any stage of the mastectomy, such as lymphedema, WHCRA mastectomy benefits must cover the cost.
WHCRA law does not apply to Medicare and Medicaid, though if you have had a mastectomy because of breast cancer, Medicare generally covers reconstructive surgery. Medicare coverage depends on individual state laws, so coverage varies depending on location.
As of 2014, the Affordable Care Act offers additional protections. This law stipulates that a group health care plan cannot limit or deny benefits to an individual with a pre-existing condition. If your employer changes insurance companies after your mastectomy, your new insurance company must cover the cost of reconstructive surgery if that insurance company covers mastectomies.
Under WHCRA requirements, insurance companies must also cover the cost of certain necessary mastectomy products, including mastectomy bras, breast forms, and post-surgical compression bras. The number and style of bras insurance must provide depends on your particular provider, medical needs, and coverage level.
What Mastectomy Products Does Insurance Cover?
Beyond covering the cost of reconstructive surgery, many insurance providers offer coverage for mastectomy products that can assist women in the recovery process.
Some women choose not to have reconstructive surgery following a mastectomy. Many health insurance companies cover custom breast prostheses (or breast forms) which are artificial breasts fabricated to look and feel natural. Most custom breast forms are silicone and either attach directly to the skin or sit securely within a pocketed bra. These policies also offer insurance coverage for lightweight foam breast forms every six months.
Many insurance companies, including Cigna Healthcare, United Healthcare, Blue Cross Blue Shield, and most Medicaid plans, will cover custom breast forms when deemed medically necessary. These plans typically cover one custom prosthesis every two years unless your doctor or plastic surgeon deems an earlier replacement necessary. Other providers, like Aetna, consider breast forms cosmetic and therefore not a medical necessity, so in some cases limit prosthetic coverage to an initial prosthesis.
After breast cancer surgery, many women require additional support and comfort as they heal. Mastectomy recovery bras are designed with front closures, seamless fabrics, and comfortable, wide straps and bands that will not irritate the surgical site.
Standard insurance policies generally cover four to six post-surgery bras yearly, though some providers only cover pocketed mastectomy bras. You will need a prescription from your oncologist before you qualify for coverage.
Most mastectomy bra claims are not processed until after the mastectomy surgery. You can be fitted for a mastectomy bra once your surgical incisions have healed and any swelling has gone down. This is generally four to six weeks after your mastectomy.
When determining your eligibility for a post-surgical bra, insurance companies care less about when you had your surgery and more about your current needs. You may still be eligible for a mastectomy bra even years after surgery.
Some insurance plans cover compression garments that help prevent lymphedema after breast surgery. Lymphedema, the accumulation of lymph fluid that causes swelling, affects between three and five million Americans. Medicaid requires coverage for certain compression tights or sleeves that help with swelling, but Medicare does not.
Let Us Help You Get Coverage
After breast cancer surgery, we know the last thing you want to do is haggle with your insurance company. The staff at A Fitting Experience Mastectomy Shoppe will assist you every step of the way.
We contact the department that reviews claims to verify your benefits and contact your doctor for a referral and any necessary records. We follow HIPAA compliance and our online portal keeps your private information safe and secure. We can also discuss affordable payment options with you if your insurance provider does not cover your needs.