Achieving balanced breasts through reconstruction

The Women’s Health and Cancer Rights Act (WHRCA) requires that most group health plans cover all stages of reconstruction of the breast(s) on which a mastectomy was performed. It also stipulates coverage of surgery and reconstruction of the other breast to produce a symmetrical or balanced appearance. 

Surgery on a breast without cancer to establish symmetry with the opposite breast is considered medically necessary when it is related to breast reconstruction following a mastectomy. Methods to create breasts of similar size and shape may include:

• Breast reduction (reduction mammoplasty) 
• Breast lift (mastopexy)
• Enhancement with a breast implant
• Autologous tissue reconstruction (e.g. DIEP, TRAM, SIEA, or Latissimus dorsi flap)
• Fat grafting

Some health insurers consider fat transfer or grafting experimental and refuse coverage of this technique. However, the American Society of Plastic Surgeons states, “Autologous fat grafting should [not] be considered experimental but should be regarded as part of reconstructive surgery when it is performed to approximate a normal appearance of the breasts following mastectomy or lumpectomy.”

Medicare & Medicaid

Medicare and Medicaid are public programs that are not bound by the WHRCA. They have their own rules. Medicare covers breast reconstruction after a "medically necessary" mastectomy typically associated with a cancer diagnosis, while Medicaid coverage varies by state.

See the Insurance & Paying for Care section of our website for more information.