Breast Reconstruction

HMSA PPO and HMO plans, in compliance with the federal Women’s Health and Cancer Rights Act of 1998, provides the following medical and surgical benefits in connection with a covered mastectomy:

• Corrective surgery required to restore, reconstruct or correct the breast on which a mastectomy was performed.
• Surgery for the reconstruction of the non-affected breast to produce a symmetrical appearance (including external or internal prostheses).
• Treatment for the physical complications of the mastectomy or reconstructive surgery, including lymphedema.

Breast reconstruction is covered when a mastectomy is covered by the member’s plan. Precertification for breast reconstructive surgery is not required when the member has a history of breast cancer.

Coverage is subject to member’s plan deductibles and copayments. In addition, HMSA will pay benefits for reconstructive surgery following mastectomy if your patient is covered by an HMSA plan when services are rendered.

Reconstructive surgery and surgery to produce symmetry must be performed within a reasonable period following the original mastectomy.

Claims Filing Information

When submitting claims for breast reconstructive surgery, please provide a copy of the surgeon’s operative report so that appropriate benefit payments can be determined.

Revision History