Does Insurance Cover Breast Reconstruction? What California Patients Should Know

What is the Women's Health and Cancer Rights Act?

WHCRA is a 1998 federal law that requires group health plans, and the insurers that sell them, to cover breast reconstruction when they cover mastectomy.

The law applies to most employer-sponsored group plans and individual health insurance policies that include mastectomy benefits. It protects patients whether reconstruction happens at the time of mastectomy or years later. Plans must also notify members of these rights when they enroll and every year.

What does breast reconstruction insurance coverage include?

WHCRA coverage includes every stage of reconstruction and symmetry procedures, not just the first operation.

Under the law, covered benefits include:

• Reconstruction of the breast on which the mastectomy was performed, including implant-based and own-tissue techniques such as the DIEP flap.
• Surgery and reconstruction of the other breast to produce a symmetrical appearance — for example, a lift or reduction.
• Prostheses, such as breast forms or implants.
• Treatment of physical complications of mastectomy, including lymphedema.

Are there other protections for California patients?

Yes. California law also requires state-regulated health plans and insurers that cover mastectomy to cover reconstruction, including symmetry procedures.

Medicare covers breast reconstruction after mastectomy for cancer, and Medi-Cal covers medically necessary reconstruction. Which rules apply depends on the type of plan you have, so the details of your own policy matter. Self-funded employer plans are governed by federal law rather than state insurance law.

What is prior authorization, and why does it matter?

Prior authorization is your insurer's approval before surgery. Most plans require it for breast reconstruction, and skipping it can lead to a denied claim.

The surgeon's office submits your diagnosis, the planned procedures and supporting records. Approval can take days to several weeks, so starting early matters — especially when reconstruction is timed with a mastectomy date.

What costs might I still pay?

Coverage does not mean zero cost: your plan's normal deductible, co-payments and co-insurance still apply, and out-of-network care may cost more.

Ask your insurer about your remaining deductible, out-of-pocket maximum, and whether the surgeon, hospital and anesthesia are in network. Cosmetic procedures unrelated to mastectomy reconstruction are not covered under WHCRA.

How does our Los Angeles office help with insurance?

Our team helps you understand your benefits, prepares and submits prior authorization requests, and coordinates with your breast surgeon's office.

If a request is denied, we can help you understand the reason and the appeal options available to you. Call (310) 267-5518 to confirm whether we work with your plan.