Breast reconstruction after mastectomy was denied. What rights do I have?
The Women's Health and Cancer Rights Act generally requires group health plans and insurers that cover mastectomy to also cover reconstruction of the breast on which the mastectomy was performed, symmetry surgery on the other breast, prostheses, and treatment of physical complications. Appeal by citing WHCRA and the plan provision, then showing the requested service fits that reconstruction right.
What to do, in order
- Step 1
Confirm the plan covers mastectomy
WHCRA applies when the plan or insurer covers mastectomy benefits.
- Step 2
Identify which reconstruction category applies
Same-breast reconstruction, symmetry surgery, prosthesis, or physical complication treatment.
- Step 3
Get the surgeon's letter
The letter should explain the relation to mastectomy and why the requested procedure is reconstructive, not cosmetic.
- Step 4
Appeal any medical-necessity criteria separately
WHCRA gives a coverage right, but plans can still apply deductibles, coinsurance, and reasonable medical-management criteria.
The deadline that applies
Use the denial letter's appeal deadline, generally at least 180 days on employer and ACA plans. If the plan denies based on medical necessity, request the criteria and the claim file.
Calculate your date →Documents to gather
- Denial letter
- Mastectomy records
- Surgeon reconstruction plan
- Plan mastectomy/reconstruction benefit language
- Photographs or measurements only if the surgeon says they are necessary
Go deeper
Related questions
Does WHCRA require symmetry surgery?
Yes, when needed to produce a symmetrical appearance after mastectomy.
Can the plan call it cosmetic?
It can try, but reconstruction connected to mastectomy has specific federal protections.
Does WHCRA erase cost sharing?
No. Deductibles and coinsurance can still apply if they are consistent with other plan benefits.
Sources
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