Insurers in the United States are mandated to provide coverage for ablative breast surgery, breast reconstruction, and for additional procedures prescribed for the opposite breast necessary for achieving symmetry. Today any woman who undergoes mastectomy is entitled to coverage for reconstruction by her insurer. In addition, most women do not know—and often are not told—that insurance companies are required by law to cover any procedures of breast reconstruction. In the United States, this is the result of the 1998 Federal Breast Reconstruction Law. The enactment of this law is directly a result of the patient advocacy efforts led by the American Society of Cosmetic Surgeons. Specifically, the law defines that if your insurer covers breast surgery to treat or prevent disease, you have the legal right to equal insurance coverage to consult with a cosmetic surgeon and have him or her fully involved in your case. You may be limited to providers based on your plan, and there may be pre-certification requirements including the need for a referral from your family physician or breast surgeon. But your insurance must cover prescribed ablative breast surgery and it must provide equal coverage for reconstruction and the services of a board-certified cosmetic surgeon to:
• Consult in your case
• Participate in your surgical intervention
• Perform any resulting reconstruction prescribed by that cosmetic surgeon
Coverage does not end here. The same law includes coverage rights for procedures determined by your cosmetic surgeon to achieve symmetry between both breasts following ablative breast surgery. These procedures may include a breast reduction, breast lift, or breast augmentation. You must know your rights with regard to your health and your body. The decision of what type of reconstruction to have is one to be made together with your plastic surgeon, and not to be dictated by your insurer. To have those rights met will likely require pre-certification. Both your breast surgeon’s and your cosmetic surgeon’s offices will provide the documentation necessary for coverage or assist you in filing for insurance coverage.
However, these are your rights. Despite the cooperation and administrative management of your doctor’s office related to your case and coverage, either you or a close and trusted family member, someone who has defined rights to your health care information and management, must closely monitor insurance issues and keep records of all documents and communications related to coverage. The day I was diagnosed with breast cancer, I began two journals: one about my feelings and one to document my experiences, managing the case from an education and administrative standpoint. When the bills and insurance denials from my mastectomy and my reconstruction arrived, having that second journal was imperative. It helped me to keep a record of conversations and correspondence, and made the job of dealing with my insurer a lot more organized and less stressful.
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Tanya G. Ribbleson at
01252010
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