“Does insurance cover my breast procedure” Every plastic surgeon is asked this question.

Patients want to know if their abdominoplasty, breast reconstruction, or breast augmentation is covered by their insurance policy.

It can be a difficult question to answer, as there is so much variability in insurance coverage from company to company and even among individual policies.

Each case has to be considered individually, and the patient should not be given a specific answer until the insurance company has provided a written response.

Insurance coverage is unpredictable when it comes to women seeking breast implants, whether for breast reconstruction or aesthetic surgery.

However, breast reconstruction—post-breast cancer—is clearly the most straightforward when it comes to insurance coverage.

State laws govern provisions the insurers must follow in the area of medical and surgical benefits for mastectomies, as well as reconstructive surgeries following mastectomies.

In 1998, the Women’s Health and Cancer Rights Act (WHRCA) was added as an amendment to the Employee Retirement Income Security Act (ERISA) laws. It required insurance companies to cover breast reconstruction for women after mastectomy as a treatment of breast cancer. Eighty-three percent of states have legislation further supporting this Act.

Alabama, Georgia, Ohio, Colorado, and Hawaii do not have state legislation supporting the Act. In Massachusetts and Puerto Rico, legislation is pending.

If a patient has a mastectomy, the laws require coverage for reconstruction and balancing procedures on the opposite breast, as well as a prosthesis for patients who elect not to have reconstruction.

Some insurance companies cover deformity after lumpectomy and radiation, including balancing procedures on the opposite breast, but this varies among plans.

If FDA-approved, medical devices, such as tissue expanders and breast implants, are usually covered by insurance.

However, Alloderm (LifeCell) used as an adjunct to breast reconstruction is not always covered by insurance. In addition, LifeCell runs a service that specifically assists patients and physicians in obtaining coverage.

For patient and physician alike, the state-by-state regulations can be very complex to unravel.

For example, in Missouri, where I practice, the Missouri Revised Statute, Chapter 376, Life, Health and Accident Insurance, Section 376.1209, indicates the following guidelines for mastectomy patients:

“Mandatory insurance coverage for prosthetic devices and reconstructive surgery—no time limit to be imposed.”

To take another example, the state of Connecticut’s similarly worded statute—Chapter 700C of the Health Insurance Act, Section 38a-504c—shall “provide benefits for the reasonable costs of reconstructive surgery on each breast on which a mastectomy has been performed, and reconstructive surgery on a nondiseased breast to produce a symmetrical appearance … For the purposes of this subsection, reconstructive surgery includes, but is not limited to, augmentation mammoplasty, reduction mammoplasty and mastopexy.”

Not all state coverage is equal. Missouri actually has one of the more comprehensive policies.

In Connecticut, the regulations will not specifically prohibit an insurance company from denying a patient the renewal of their coverage due to a history of breast cancer or previous breast reconstruction.

The State of Missouri does not allow insurances covered under ERISA and WHRCA to deny a patient renewal based on previous cancer treatment.

WHAT DO THEY COVER?

Revisional procedures are somewhat less straightforward. Most insurance companies will cover revision of implant breast reconstruction for documentation of a leaking implant.

In addition, insurance companies often cover the treatment of capsular contracture. However, there are fewer consensuses among insurance companies for “cosmetic” revision of a breast reconstruction. This would include procedures performed because of asymmetry caused by weight gain or loss or malposition of an implant (too high or too low).

Very few plans cover the removal of implants for autoimmune disease or patient’s fears concerning breast implants, because there is no data supporting any link between silicone implants and any systemic disease.

Congenital breast asymmetry is a “gray area” regarding insurance coverage. Most plans will only consider coverage for congenital asymmetry for a diagnosis of Poland’s Syndrome.

Alternatives to Implant Coverage

Allergan Inc and Mentor Corp offer warranty programs covering reoperation for rupture within 10 years of the implant’s placement. Each firm’s plan varies; upgrades to higher coverage are available.

Each company offers automatic enrollment at no cost to the patient for silicone and saline breast implants, and the terms cannot be cancelled.

The Allergan ConfidencePlus Warranty offers lifetime replacement of a ruptured Allergan implant, and up to $1,200 in coverage for out-of-pocket expenses for operating room and anesthesia costs for replacement surgery (not covered by insurance).

For a one-time $100 payment, Allergan also offers additional coverage—up to $2,400 in financial assistance.

Allergan currently offers a no-cost warranty for all silicone gel implants.

Mentor offers an optional extended limited warranty, the Mentor Enhanced Advantage, which is above and beyond the protection offered by the standard Mentor Advantage program.

The benefits include operating room, anesthesia, and surgical charges not covered by insurance. As with Allergan’s coverage plan, the term is for 10 years and up to $2,400 in financial assistance.

This optional limited warranty is available with both saline-filled and silicone-filled breast implant products. To be eligible, patients must enroll within 45 days of implantation for a $100 fee.

Some plastic surgeons use CosmetAssure, an insurance plan that covers medical complications of aesthetic procedures that occur in the first 30 days following surgery.

This includes infection, bleeding, DVT, and pulmonary embolus that the patient’s medical insurance may not cover.

The entire list of covered complications is posted on the firm’s Web site. The surgeon must use the insurance on all of his or her aesthetic patients at a cost of $150 to $200 per procedure, depending on the geographical region.

As with all insurance policies, CosmetAssure enforces certain limitations, but the service can be useful if an unexpected complication occurs that requires hospitalization or revisional surgery.

The insurance does not cover surgery due to unacceptable aesthetic results or a patient’s desire to have a larger or smaller implant size, or to correct an asymmetry.

No matter what the coverage or company, you should inform patients about all benefits and limitations.

None of the plans cover reoperation to correct capsular contracture or aesthetically unacceptable results. Plastic surgeons may or may not charge patients for reoperation.

You should provide patients with a written description of your policy, in advance of surgery, so that you can avoid any confusion on this important point.

—PM

Some will consider coverage associated with pectus excavatum deformity, and a few will consider unilateral breast reduction if the patient meets the company’s criteria for breast reduction. This coverage is variable and needs to be predetermined for each case.

BREAST AUGMENTATION

The biggest recent change in coverage is for complications after aesthetic breast augmentation.

After the FDA imposed a moratorium in 1992 on the use of silicone breast implants, many patients sought coverage for removal of their silicone implants.

Initially, because of the concerns of a possible link between silicone gel and autoimmune diseases, many insurance companies paid for the removal of gel implants but rarely paid for replacements.

After numerous studies showed no link between silicone gel and autoimmune disease, the number of insurance companies willing to pay for removing implants has dropped dramatically.

In 2008, very few insurance companies will cover any cost of revisional surgery for aesthetic breast augmentation, even with documentation of rupture.

Some companies will consider coverage for rupture of a silicone breast implant after aesthetic breast augmentation, but not for a ruptured saline implant. Insurance carriers rarely cover capsular contracture when it is related to aesthetic breast augmentation.

Medications for treating capsular contracture, such as Singulair (by Merck), are also not usually covered by insurance.

The insurance company’s stand is that if the patient chooses to pay for aesthetic breast augmentation, all costs related to the surgery are the patient’s responsibility.

There have been concerns about insurance companies limiting coverage for any breast disease in women who have had elective aesthetic breast augmentation, but there are no current reports of this policy being implemented, to my knowledge.

EXPLAIN YOUR POLICY

Clearly, the right answer to the patient’s “Is it covered?” question is variable and depends on the insurance plan and the patient’s specific policy.

When performing surgery on patients with breast implants—whether it be for reconstruction, revision, aesthetic augmentation, or congenital asymmetry—plastic surgeons must learn as much as they can about the insurance plans offered.

Their staffs should also be knowledgeable about the nuances and pitfalls of insurance coverage.

Understanding the policies of the most common insurance plans in the physician’s area can be extremely useful when patients call to make an appointment.

Allowing the patient to come into the office with a realistic idea of her chances of obtaining insurance coverage makes the consultation process go smoother.

Each patient should be advised to check with their own insurance company on all relevant issues.

Even if they do receive an approval, patients should be encouraged to confirm the deductible and copay amounts for which they will be responsible.

Additionally, women with breast implants need to understand that implants do not last a lifetime, and that additional surgery may be required at a future date.

The patient should be thoroughly informed—by you, if necessary—about his or her financial responsibilities prior to surgery. Very few patients understand their insurance coverage, which is the way policies are designed.

The more confusing the language is and complicated the process is, the less likely the patient will file a claim. Insurance companies benefit directly from this unfortunate practice.

See also “Back in Business” by Malcolm D. Paul, MS, FACS in the April 2007 issue of PSP.

It is very rare for insurance to cover anything medical at 100%. Also, carriers change their policies frequently.

Again, you should give your patients a written policy explaining your policy on how insurance claims are handled.

The policy statement should explain the limitations of insurance coverage and how the coverage can change without notification.

In the end, just staying informed can help both physician and patient navigate the confusing world of insurance.


Patricia McGuire, MD, is a board-certified plastic surgeon in private practice in St Louis. She can be reached at [email protected]