Breast reconstruction denials
Reconstruction after mastectomy, symmetry procedures on the other breast, revisions, and prostheses are denied as 'cosmetic' or 'not medically necessary'. A federal law decides most of these cases.
The rule that controls this: The Women's Health and Cancer Rights Act of 1998 requires group health plans and insurers that cover mastectomy to also cover reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses, and treatment of physical complications including lymphedema, in consultation with the patient and physician (29 U.S.C. 1185b; 42 U.S.C. 300gg-52). Medicare covers reconstruction after mastectomy as well. Plan criteria for staging and revisions must be disclosed on request.
Last reviewed 13 September 2026 · General information, not legal or medical advice · Apellica is not a law firm
What gets denied
- Reconstruction delayed beyond a plan's stated window after mastectomy
- Symmetry surgery on the unaffected breast
- Revision procedures, fat grafting, and nipple reconstruction
- Implant exchange or removal for complications
- Prostheses and lymphedema treatment
Common denial reasons
- Plan labels the procedure 'cosmetic'
- Plan applies a time limit after the mastectomy
- Staged procedure treated as elective rather than part of reconstruction
- Documentation does not connect the procedure to the mastectomy
- Coding submitted as cosmetic rather than reconstructive
How we approach the appeal
Cite the Women's Health and Cancer Rights Act by name and section in the appeal, and attach the mastectomy operative report and the surgeon's letter connecting each procedure to reconstruction or symmetry. The law contains no time limit for reconstruction; if the plan applies one, ask for the plan language. Ask the surgeon's office to confirm the procedure and diagnosis codes reflect reconstruction. Complications and lymphedema treatment are expressly covered.
Internal appeal: at least 180 days to file for commercial and employer plans; pre-service decisions within 30 days (29 CFR 2560.503-1). Medicare Advantage: 65 days to request reconsideration. External review within 4 months of the final internal denial for ACA-covered plans.
Reconstruction is a series of hospital and surgical procedures; the amount at stake is the plan's allowed amount for each denied stage.
- · The denial letter with the reason stated
- · Mastectomy operative report and pathology
- · Surgeon's letter linking the denied procedure to reconstruction or symmetry
- · Photographs or clinical notes documenting asymmetry or complications where relevant
- · Plan document language on reconstruction
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Breast reconstruction denials by insurer
What each plan tends to cite, and the rule that controls it.
- UHC breast reconstruction denials
- Aetna breast reconstruction denials
- Cigna breast reconstruction denials
- BCBS breast reconstruction denials
- Humana breast reconstruction denials
- Medicare breast reconstruction denials
- Kaiser breast reconstruction denials
- Ambetter breast reconstruction denials
- Molina breast reconstruction denials
- BCBS FEP breast reconstruction denials
- WellCare breast reconstruction denials
This page provides general information about appeal strategy. It is not legal advice. Outcomes depend on documentation, plan terms, and timing.