Of the hundreds of thousands of women each year who are diagnosed with breast cancer, most who get a mastectomy decide to follow it with breast reconstruction. Although today it seems easy and natural to get reconstruction after mastectomy, breast cancer advocacy groups, patients and physicians have been fighting for years to get insurance companies to cover these medically necessary reconstructions.

And it’s been a long struggle. Throughout the 1980s and 1990s, insurance companies in every state began limiting the procedures they considered medically necessary, or denied coverage completely, dismissing reconstruction as "cosmetic" surgery. Physicians and their patients were forced to fight case-by-case, appeal after appeal, for coverage of breast reconstruction and procedures to create symmetry on the opposite breast.

In 1997, only thirteen states had laws mandating insurance companies cover breast reconstruction. Because of the combined efforts of breast advocacy groups, such as The American Cancer Society and The American Society of Plastic Surgeons, a new law was drafted and in January of 1998, New Jersey was the first state to pass a version of the Women’s Health and Cancer Rights Act. In October of 1998, Congress made the Act a federal law requiring group health plans and health insurance companies that provide medical benefits covering mastectomy, to also cover the cost of reconstructive breast
surgery for women who have undergone a mastectomy. Coverage must include all stages of reconstruction as well as procedures to restore and achieve symmetry to the opposite breast, and the cost of prosthesis, implants and complications. There are no time restrictions on when reconstruction must be initiated, which is important, since many women face post-operative chemotherapy or radiation and often choose to delay their breast reconstruction.

In addition, the attending physician and patient are to be consulted in determining the appropriate type of surgery, and group health plans and health insurance issuers offering group health coverage may not deny a patient eligibility or continued eligibility to enroll or renew coverage under the terms of the plan just because they want to avoid meeting the requirements of the statute.

Why You Need to Take Action on The Act

Despite the existence of The Act, The battle for women’s rights to coverage for breast reconstruction is not over. In fact, a recent nationwide survey on women’s awareness of breast reconstruction options, showed that over 75% of the women did not know that the Women’s Health and Cancer Rights Act mandated health insurance companies to cover breast reconstruction. Insurance companies are working hard to whittle down coverage by dramatically reducing their reimbursement for breast reconstruction and bundling separate procedures together, causing physicians and their patients to justify and fight for medically necessary procedures. If patients choose a more experienced physician who is out of network, they are often required to pay for a larger percentage of their reconstruction.

Clearly, women need to be educated to protect themselves against improper treatment or denial of care by insurance carriers, starting from their initial diagnosis of breast cancer, through the final touches of their breast reconstruction. Armed with the facts, women facing breast cancer will be able to be treated by the physicians they choose, so they can improve their chances of survival, while also restoring their body image and self esteem. That’s a goal worth fighting for.

Caroline A. Glicksman, MD, is a board-certified plastic and reconstructive surgeon in practice in Sea Girt and Red Bank, New Jersey since 1991. She pioneered the legislative fight mandating insurance coverage for breast reconstruction after mastectomy.