By IHPL - July 2, 2020

“Will my insurance company pay for that?”

I’m surprised how often I get asked this question.

I’ve been a breast surgeon for over 20 years and have had the privilege of taking care of many women who have breast cancer. While most women who have breast cancer today are able to save their breast with successful treatment of their cancer, in some cases, women choose to or must have their entire breast removed in a procedure called a “mastectomy.”1 In other cases, when someone is born with a rare cancer-causing gene (like BRCA1 or BRCA2), her risk of developing breast cancer is so high that we may recommend that she have her breasts removed to prevent developing breast cancer in the future.

The loss of one’s breast is obviously life-changing and, for some women, can have profound effects on self-esteem, body image, and sexuality.2 Fortunately, surgical techniques to remove a woman’s breast have advanced dramatically in recent years. Rather than what previously was considered a radical mastectomy, we are now often able to remove the entire breast through small incisions with hidden scars that allow a woman to save her nipple and areola through a procedure called a “nipple-sparing mastectomy.” Following the breast and cancer removal, a plastic surgeon can rebuild the breast with an implant or one’s own extra tissue (fat from the abdomen or tummy tuck tissue).3 At this point in my explanation is often when I get asked the question about insurance coverage.

The Women’s Health and Cancer Rights Act (WHCRA) of 1998

WHCRA requires insurance companies to cover reconstruction of the breast, as well as the opposite breast (to create symmetry), after a mastectomy.4 The law goes further to require coverage if you have other medical conditions such as a high risk gene even if you don’t have cancer yet. WHCRA requires coverage for the following:

  • All stages of reconstruction of the breast on which the mastectomy was performed
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance
  • Prostheses
  • Treatment of physical complications of the mastectomy, including lymphedema

There are few exceptions to this law for some types of government and church insurances, but in general, most women who need to have a mastectomy also have insurance coverage for reconstruction of their breasts. It is important to confirm specific details with your health insurer.

In this era of climbing health care costs and an emphasis on value-based care,5 where “value” is defined as quality divided by cost, the quality of the care that a patient receives must include the sum total of that experience. Most surgeons can measure quality by how many surgical complications they may have or how often a cancer comes back. I would argue that how a woman feels about her body after removing her breast through an operation is one of the most important after-surgery quality measures we need to define.

The day may come soon where limited health care dollars will limit coverage to only “medically necessary” services. Though less tangible and much harder to measure, this feeling of wholeness after surgery is well worth the investment, protected for now by the WHCRA.

Author Bio:

Sharon Lum, MD

Sharon Lum, MD

Dr. Lum is a Professor and Vice Chair of Academic Affairs of the Department of Surgery for the Loma Linda University School of Medicine. She serves on the Quality Integration Committee for the Commission on Cancer for the American College of Surgeons. Her research interests include quality measures and disparities in breast and other cancer outcomes and incorporation of patient reported outcomes in clinical decision-making for patients with breast diseases.

References

  1. https://www.cancer.org/cancer/breast-cancer/treatment/surgery-for-breast-cancer.html
  2. Hart AM, Pinell-White X, Losken A. The Psychosexual Impact of Postmastectomy Breast Reconstruction. Ann Plast Surg. 2016;77(5):517–522
  3. https://www.cancer.gov/types/breast/reconstruction-fact-sheet
  4. https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/publications/your-rights-after-a-mastectomy.pdf
  5. https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0558

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