For Consumers

Insurance and reconstructive breast surgery

7 out of 10 women don't know they have the right to reconstructive breasts surgery post-mastectomy.

The choice to rebuild your breasts after a mastectomy is yours.

Knowing your insurance rights can help with your decision.

Under state and federal law (www.cms.gov), if your insurance company covers mastectomies, it must also cover related services, including reconstructive surgery and breast prostheses or forms if you don't select surgery. This is true even if the mastectomy is not due to a cancer diagnosis and even if your surgery is delayed. Coverage must include:

  • All stages of reconstruction of the breast on which the mastectomy has been performed;
  • Surgery and reconstruction of the other breast to produce a symmetrical or balanced appearance;
  • Any external prostheses that fit into your bra before or during the reconstruction;
  • Treatment of physical complications of all stages of the mastectomy, including lymphedema or fluid build-up in the arm or chest; and
  • Any medically necessary hospitalization for treatment.

Your insurer must notify you of this coverage when you enroll and every year after.

Are there any coverage exceptions?

All individual health and employer-sponsored health plans that cover mastectomies also cover breast reconstruction services. Self-funded health plans must apply for an exemption from the federal government if they wish to exclude the coverage. Medicare and Washington Apple Health (Medicaid) also cover breast reconstruction surgery and services after a mastectomy. Contact your employer's health plan administrator if you have questions about your coverage.