Insurance Coverage for Breast Reconstruction

Does insurance cover breast reconstruction?

If you have had a mastectomy, or are facing one, federal law is on your side. Even so, women are still denied, particularly when they need revision surgery, and it leaves them understandably confused. This page explains why that happens and what can be done about it.

Having a lumpectomy rather than a mastectomy? See oncoplastic and symmetrizing breast reduction on our breast reduction insurance page.

Your rights under federal law

The Women's Health and Cancer Rights Act requires group health plans that cover mastectomy to also cover:

• Reconstruction of the breast that was removed
• Surgery on the other breast to achieve a symmetrical appearance
• Breast prostheses
• Treatment of physical complications, including lymphedema

Your usual deductibles and coinsurance still apply, and the law protects you whether your reconstruction is done at the time of your mastectomy or many years later.

So why are reconstruction patients still denied?

This catches many women off guard, and it is worth understanding. The law requires your plan to cover reconstruction. What it does not do is take away your insurance company's right to decide whether a particular operation is medically necessary, or stop them classifying one as cosmetic.

Revisions are where that becomes a problem. If an earlier reconstruction has left you with asymmetry, a contour deformity or dog ears, your insurance company may look at the request and call it cosmetic, even though what is being corrected is the result of your cancer surgery.

Revision after aesthetic flat closure

We hear regularly from women who chose to go flat, were left with loose folds of skin or prominent dog ears under the arms, and were then told that correcting it is cosmetic. It is not. A flat closure is a form of reconstruction, and a result that leaves you unable to wear normal clothing, or causes the skin to rub and break down, is a surgical result that needs revising.

Dr. Li has taken cases like these to peer-to-peer review with insurance medical directors and has had denials overturned for women in exactly this position. Every case is different and no outcome can be guaranteed, but a denial is a decision, and decisions can be challenged.

Dr.Li is a very skilled surgeon, that has extensive experience working with breast cancer patients and performing reconstruction. While she does offer various options including implants and LAT Flap, I went to her specifically for an Aesthetic Flat Closure (AFC) Revision. In August 2024, I was diagnosed with breast cancer and chose a double mastectomy. Another plastic surgeon left me with less than desirable results, despite my specific requests for a “one and done flat closure”. The outcome was not “aesthetic” and caused unnecessary trauma, physical and emotional pain. Los Angeles has an abundance of plastic surgeons. But, finding one that truly understands women, supports AFC and can do it well, is daunting. One year after my mastectomy, another breast cancer patient referred me to Dr. Li and her Nurse Practitioner, Traci. When I first contacted the office, I was surprised that Dr. Li answered the phone herself! She took her time speaking with me, getting to know me and put me at ease. As the call ended, I felt a sigh of relief. I felt heard and knew I had finally found a surgeon that could help me. Dr. Li is compassionate, inquisitive and never once questioned my flat decision. She did not try to talk me out of it or upsale other procedures. She was validating, caring and respectful. The communication between Dr. Li and Traci before, during and after the surgery was bar none. If I had a question, I heard from them promptly. Both clearly communicated pre op and post op instructions and were genuinely concerned with my wellbeing. My appointments never felt rushed. Dr. Li also easily worked with my insurance. As far as the revision, Dr. Li did an excellent job and exactly as requested. She exceeded any expectations I had! I have a completely flat closure and she removed the “dog ears” (extra skin left by other surgeon) on my back. When I developed a complication (not by her doing), she addressed it promptly. The scars are clean and thin. But, most importantly, the pain and discomfort from the original surgeon’s closure is gone! Dr Li also coordinated care with other providers. Dr. Li and Traci did not miss a detail. I have worked in healthcare for over 30 years. I have come across many providers both personally and professionally. I can tell you, with 100% confidence, Dr. Li and Traci are one of a kind, both as medical providers and human beings. I’m so grateful to have found them. Dr. Li’s skill, knowledge, expertise, attention to detail, empathy and integrity are rare in today’s healthcare environment. I highly recommend Dr. Li. Find comfort in knowing you will be in good and caring hands, both figuratively and literally!

Revision after surgery elsewhere

Many of our patients come to us after reconstruction performed by another surgeon, sometimes years earlier, and some travel from out of state to do so. Revision reconstruction is one of Dr. Li's areas of particular expertise, and it is a large part of what she does.

Dr. Li to the rescue! After other surgeons performed two botched breast reconstructions following a mastectomy, I consulted with nurse Tracey and Dr. Li. Both went above and beyond to put me at ease and reassure me that they could help. They worked with my insurance company for pre-surgery approval and scheduled my revision in a facility that accepted my coverage. To my surprise, Dr. Li even called me the night before the surgery to answer any last minute questions and concerns. The surgery went very well and corrected the previous asymmetry. They have continued to check in with me frequently and made me feel supported and cared for. I can't recommend Dr. Li, Tracey and her entire compassionate, organized and highly skilled team enough.

What we do when your reconstruction is denied

Our team documents the symptoms and the practical problems your current result is causing you, photographs it, and prepares the medical case. Dr. Li then requests a peer-to-peer review with your insurance company's medical director and explains why the surgery is reconstructive rather than cosmetic. If the denial still stands, you have the right to appeal, and depending on your plan, to an independent external review.

More on using your insurance

• How we work with your insurance, from the benefits check to appeals
• Insurance coverage for breast reduction
• Revision breast reconstruction with Dr. Li

Call our office at 626.888.9728 to schedule your consultation, or request an appointment online.

The information on this page is general and is not a guarantee of coverage. Every insurance plan is different, and coverage decisions are made by your insurance company.