INSURANCE ISSUES: BREAST RECONSTRUCTION FOLLOWING DIAGNOSIS AND TREATMENT OR BREAST CANCER: RECOMMENDED INSURANCE COVERAGE CRITERIA FOR THIRD-PARTY PAYERS

Background

For women, the function of the breast, aside from the brief periods when it serves for lactation, is an organ of female sexual identity. The female breast is a major component of a woman's self image and is important to her psychological sense of femininity and sexuality. Individuals with abnormal breast structure(s) often suffer from a severe negative impact on their self esteem, which may adversely affect their sense of well-being. Breast cancer is the second most frequently occurring cancer in the United States. Breast reconstruction after cancer treatment is the most common reason patients seek breast reconstruction surgery. Many women find that surgical reconstruction of the missing breast is an essential component in their recovery from cancer.

Definition: Cosmetic and Reconstructive Surgery

For reference, the following definition of cosmetic and reconstructive surgery was adopted by the American Medical Association, June 1989:

Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.

Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.

Policy

Breast reconstruction of the affected breast, as well as surgery on the contralateral breast to achieve symmetry, is considered reconstructive surgery and in accordance with the Women's Health and Cancer Rights Act must be a covered benefit and reimbursed by third-party payers.
Legislation: Women's Health and Cancer Rights Act of 1998
In October 1998, federal legislation was signed into law requiring group health plans and health issuers that provide medical and surgical benefits with respect to mastectomy, to cover the cost of reconstructive breast surgery for women who have undergone a mastectomy. The law states:

· The attending physician and patient are to be consulted in determining the appropriate type of surgery.

· Coverage must include all stages of reconstruction of the diseased breast, procedures to restore and achieve symmetry on the opposite breast and the cost of prostheses and complications of mastectomy, including lymphedema.

Group health plans and health insurance issuers offering group health coverage may not:

· Deny a patient eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely for the purpose of avoiding the requirements of the statute.

· Penalize, reduce, or limit the reimbursement of an attending provider.

· Provide incentives to attending provider to induce such provider to provide care to an individual participant or beneficiary in a manner inconsistent with this section.

The statute extends the requirement to self-insured plans under ERISA federal law, and preempts state laws that do not provide at least the same level of coverage. Violations of this federal legislation may be reported to the Department of Labor at (202) 219-8776.

Surgical Treatment of Breast Cancer

Mastectomies can be segmental, partial, complete or total (modified radical or radical with muscle resection). Mastectomies can be indicated for malignant, pre-malignant or in rare situations, for benign disease processes.

Lumpectomy, also referred to as a tylectomy, is the surgical excision of a cancerous lump along with a margin of normal breast tissue. Twenty percent to 30 percent of patients undergoing a lumpectomy will be left with breast deformities that vary greatly depending on the type of resection, radiation therapy, breast size and shape, and tumor location.

Reconstruction Following the Treatment of Breast CancerA variety of reconstruction techniques are available to accommodate a wide range of breast deformities resulting from mastectomy or lumpectomy. The technique(s) selected are dependent on the nature of the defect, the patient's individual circumstances and the surgeon's judgment. When developing the surgical plan, the surgeon must correct underlying deficiencies, as well as take into consideration the goal of achieving bilateral symmetry.

Depending on the individual patient circumstances, surgery on the contralateral breast may be necessary to achieve symmetry. Surgical procedures on the opposite breast may include reduction mammaplasty and mastopexy with or without augmentation.

References

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5. Greene, MH. Genetics of breast cancer. Mayo Clinic Proc. 72: 54-65, 1997.

6. Chang, DW., Kroll, SS., Dackiw, A., et al. Reconstructive management of the contralateral breast in patients who previously underwent unilateral breast reconstruction. Plast. Reconstr. Surg. 108: 352, 2001.

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8. www.dol.gov/ebsa.Accessed 3/16/04.

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