Breast Reconstruction Coverage

Breast reconstruction is a protected benefit

Breast reconstruction after a mastectomy is not merely an optional procedure—it is an essential component of comprehensive breast care. Federal law offers important protections to ensure that eligible patients can choose reconstruction without sacrificing their insurance coverage. Our team collaborates closely with you and your insurance provider, so financial considerations do not prevent you from feeling whole again.

Important: This page summarizes key protections but is not legal advice. Coverage can vary by plan. Always confirm your specific benefits with your insurer or employer.

The Women’s Health and Cancer Rights Act (WHCRA)

The Women’s Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that applies to most group health plans and health insurance issuers that offer coverage for mastectomies.

If WHCRA applies to your plan and it covers your mastectomy, it must also cover certain post-mastectomy benefits when you choose reconstruction (Fact Sheet: Women's Health and Cancer Rights Act).

Required benefits include coverage for:

All stages of reconstruction of the breast on which the mastectomy was performed
Surgery on the opposite breast, when needed, to achieve a symmetrical appearance
External prostheses (breast forms), if needed
Treatment of complications from mastectomy or reconstruction, including lymphedema

These services must be covered in a manner consistent with how the plan covers other medical and surgical benefits—subject to the usual deductibles and coinsurance under your policy (Your Rights After a Mastectomy).

WHCRA Timelines

WHCRA does not require you to have reconstruction immediately. In many cases, you may choose reconstruction:

At the time of mastectomy
Months or years later
After the previous reconstruction, if you are unhappy with the result or need revision

As long as WHCRA applies and your plan covers the mastectomy, the law generally requires coverage of post-mastectomy reconstruction and related care, even when it takes place at a later stage.

Who is Covered?

In general, WHCRA protections apply to:

Most employer group health plans (including many self-funded plans)
Group and individual health insurance policies that provide medical/surgical benefits and cover mastectomies

Some plans, such as those offered by certain churches or governments, may not be subject to WHCRA. In practice, many still choose to provide similar coverage; however, it’s essential to confirm directly with your plan (Women's Health and Cancer Rights | U.S. Department of Labor).

How Richmond Plastic Surgeons Supports Your Reconstruction Coverage

Our surgeons have extensive experience in both cosmetic and reconstructive breast surgery, including complex revision and symmetry procedures. As part of your care, our team will:

Review your insurance benefits and help determine whether WHCRA likely applies to your plan
Coordinate with your breast surgeon and oncology team to plan the timing and staging of reconstruction
Submit documentation to your health plan, including operative notes, clinical photographs (when needed), and letters of medical necessity
Assist with appeals if a medically necessary reconstruction-related service is denied

Our goal is to advocate for coverage that aligns with both federal protections and the reconstructive plan you and your surgeon design together.

What You Can Do as a Patient

Before surgery, consider:

Calling the number on your insurance card and asking:
- “Is my plan subject to the Women’s Health and Cancer Rights Act?”
- “What are my out-of-pocket costs for mastectomy and reconstruction?”
- “How is symmetry surgery on the opposite breast covered?”
Requesting a summary of benefits for mastectomy and reconstruction in writing.
Sharing this information with our office so we can help you confirm that the plan details match what we are being told as providers.

If you ever feel that your reconstruction-related services are not being covered as required, you can also consult the U.S. Department of Labor and CMS resources for WHCRA and post-mastectomy rights.