Most private insurers cover prophylactic surgery for certain high-risk people

While not required under the Patient Protection and Affordable Care Act (ACA) or any national law, the vast majority of private health plans cover risk-reducing surgeries such as mastectomy, hysterectomy, salpingo-oophorectomy, colectomy or gastrectomy for people with an inherited genetic mutation linked to increased risk of cancer. For those without a known hereditary mutation, some insurers will consider coverage of surgery for individuals who have a high lifetime risk of cancer as identified by models that assess family history of cancer and other factors.

The Women’s Health and Cancer Rights Act (WHRCA) requires that most group health insurers cover breast reconstruction or prostheses following a mastectomy.

While these surgeries may be covered by the health insurer, they are not reimbursed at 100%. Some people encounter high out-of-pocket costs because deductibles, coinsurance and copayments apply. Using in-network versus out-of-network providers can minimize your costs.

Medical Necessity

Despite established expert medical guidelines recommending preventive surgery for certain people, some health plans do not consider prophylactic surgery medically necessary, even if you have a high risk of cancer. Self-funded and short-term health plans are more likely to take this stance—especially for risk-reducing mastectomy. These insurers may deny coverage if a woman decides to remove both healthy breasts to reduce her risk of breast cancer, or when a woman having a mastectomy to treat breast cancer in one breast wants to remove the other, healthy breast as well.

If coverage of your surgery is denied, we encourage you to file an appeal. Ask your surgeons and other health care providers to write letters of medical necessity, explaining your high-risk status. Visit our Health Insurance Appeals webpage for downloadable sample appeal letters citing national, evidence-based medical guidelines.