INSURANCE ISSUES: BREAST RECONSTRUCTION FOLLOWING DIAGNOSIS AND TREATMENT OR BREAST CANCER:
RECOMMENDED INSURANCE COVERAGE CRITERIA FOR THIRD-PARTY PAYERS
For women, the function of the breast, aside from the brief periods when it
serves for lactation, is an organ of female sexual identity. The female breast
is a major component of a woman's self image and is important to her
psychological sense of femininity and sexuality. Individuals with abnormal
breast structure(s) often suffer from a severe negative impact on their self
esteem, which may adversely affect their sense of well-being. Breast cancer is
the second most frequently occurring cancer in the United States. Breast
reconstruction after cancer treatment is the most common reason patients seek
breast reconstruction surgery. Many women find that surgical reconstruction of
the missing breast is an essential component in their recovery from cancer.
Definition: Cosmetic and Reconstructive Surgery
For reference, the following definition of cosmetic and reconstructive
surgery was adopted by the American Medical Association, June 1989:
Cosmetic surgery is performed to reshape normal structures of the body in
order to improve the patient's appearance and self-esteem.
Reconstructive surgery is performed on abnormal structures of the body,
caused by congenital defects, developmental abnormalities, trauma, infection,
tumors or disease. It is generally performed to improve function, but may also
be done to approximate a normal appearance.
Breast reconstruction of the affected breast, as well as surgery on the
contralateral breast to achieve symmetry, is considered reconstructive surgery
and in accordance with the Women's Health and Cancer Rights Act must be a
covered benefit and reimbursed by third-party payers.
Health and Cancer Rights Act of 1998
In October 1998, federal legislation
was signed into law requiring group health plans and health issuers that provide
medical and surgical benefits with respect to mastectomy, to cover the cost of
reconstructive breast surgery for women who have undergone a mastectomy. The law
· The attending physician and patient are to be consulted
in determining the appropriate type of surgery.
· Coverage must include all stages of reconstruction of
the diseased breast, procedures to restore and achieve symmetry on the opposite
breast and the cost of prostheses and complications of mastectomy, including
Group health plans and health insurance issuers offering group health
coverage may not:
· Deny a patient eligibility, or continued eligibility,
to enroll or to renew coverage under the terms of the plan, solely for the
purpose of avoiding the requirements of the statute.
· Penalize, reduce, or limit the reimbursement of an
· Provide incentives to attending provider to induce such
provider to provide care to an individual participant or beneficiary in a manner
inconsistent with this section.
The statute extends the requirement to self-insured plans under ERISA federal
law, and preempts state laws that do not provide at least the same level of
coverage. Violations of this federal legislation may be reported to the
Department of Labor at (202) 219-8776.
Surgical Treatment of Breast Cancer
Mastectomies can be segmental, partial, complete or total (modified
radical or radical with muscle resection). Mastectomies can be indicated for
malignant, pre-malignant or in rare situations, for benign disease processes.
Lumpectomy, also referred to as a tylectomy, is the surgical excision of
a cancerous lump along with a margin of normal breast tissue. Twenty percent to
30 percent of patients undergoing a lumpectomy will be left with breast
deformities that vary greatly depending on the type of resection, radiation
therapy, breast size and shape, and tumor location.
Reconstruction Following the Treatment of Breast CancerA variety of
reconstruction techniques are available to accommodate a wide range of breast
deformities resulting from mastectomy or lumpectomy. The technique(s) selected
are dependent on the nature of the defect, the patient's individual
circumstances and the surgeon's judgment. When developing the surgical plan, the
surgeon must correct underlying deficiencies, as well as take into consideration
the goal of achieving bilateral symmetry.
Depending on the individual patient circumstances, surgery on the
contralateral breast may be necessary to achieve symmetry. Surgical procedures
on the opposite breast may include reduction mammaplasty and mastopexy with or
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