INSURANCE ISSUES: BREAST RECONSTRUCTION RESOURCES: STATE LAWS

Insurance Coverage Required for Post-Mastectomy Breast Reconstruction If Mastectomy Is Covered

Alabama:

Provides that federally funded and publicly funded state programs that provide coverage for mastectomy surgery shall also provide coverage for reconstruction of the breast. [Section 22-6-10]

Alaska:

Conforms state law to federal standards. Provides that health care insurers providing medical and surgical benefits for mastectomies must comply with 42 U.S.C. 300gg-52 regarding coverage for reconstructive surgery following mastectomies. [Sec. 21.42.400]

Arizona:

Arkansas:

Provides that every health benefit plan that provides coverage for mastectomy surgery shall also provide coverage for reconstruction of the breast. [23-99-405]

California:

Treatment for breast cancer shall include coverage for prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. [10123.8.(d)]

Connecticut:

Provides benefits for the reasonable costs of reconstructive surgery on each breast on which a mastectomy has been performed, and reconstructive surgery on a non-diseased breast to produce asymmetrical appearance. [Sec. 38a-504(c)]

Delaware:

Coverage available for (1) all stages of reconstruction of the breast on which the mastectomy was performed; (2) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (3) prostheses and physical complications of mastectomy, including lymph edemas. [§3563]

Florida:

Covers prosthetic devices and reconstructive surgery incident to mastectomy, including surgery to reestablish symmetry; surgery must be in a manner chosen by the treating physician. [627.6417]

Illinois:

Coverage for breast reconstruction in connection with a mastectomy shall include (1) reconstruction of the breast upon which the mastectomy was performed; (2) surgery and reconstruction of the other breast to produce a symmetrical appearance; and (3) prostheses and treatment for physical complications at all stages of mastectomy, including lymph edemas. [ 215 ILCS 5/356g]

Indiana:

Covers prosthetic devices and all stages of reconstructive surgery, in the manner determined by theattending physician and patient, including reconstruction of the other breast to produce symmetry. [27-13-7-14]

Kansas:

Covers breast reconstruction, including surgery of the other breast to produce a symmetrical appearance, prostheses and physical complications, in a manner determined in consultation with the attending physician and the patient. [40-2,166]

Kentucky:

Provides coverage for breast reconstruction, including surgery of the other breast to produce asymmetrical appearance, prostheses and physical complications, in a manner determined in consultation with the attending physician and the patient. [304.18-0983]

Louisiana:

Includes coverage for reconstruction of the breast on which the mastectomy has been performed, coverage for surgery and reconstruction of the other breast to produce a symmetrical appearance, and coverage for prostheses and physical complications, all stages of mastectomy, including lymph edemas and such coverage shall be in a manner determined in consultation with the attending physician and the patient. [22:250.17]

Maine:

Provides coverage for reconstruction of the breast on which surgery has been performed and surgery and reconstruction of the other breast to produce a symmetrical appearance if the patient elects reconstruction and in the manner chosen by the patient and the physician. [§2837-C(2)]

Maryland:

Requires coverage for reconstructive surgery resulting from a mastectomy, including surgery performed on a non-diseased breast to establish symmetry. [§15-815]

Michigan:

Covers breast cancer rehabilitative services, delivered on an inpatient or outpatient basis, includingreconstructive plastic surgery and physical therapy. [500.3616]

Reconstructive surgery and prosthetic devices are covered after the attending physician has certified medical necessity. [500.3613]

Minnesota:

Covers all reconstructive surgery incidental to or following injury, sickness or other diseases of the involved part, or congenital defect for a child. Specifically includes benefits for all stages of reconstruction following mastectomy, including surgery and reconstruction of the other breast to produce a symmetrical appearance and prostheses. Also specifies that limitations on reconstructive surgery do not apply to reconstructive breast surgery following medically necessary mastectomy. [62A.25].

Missouri:

Covers prosthetic devices and reconstructive surgery necessary to achieve symmetry, as recommended by the oncologist or primary care physician. [376.1209]

Montana:

Covers reconstructive surgery following a mastectomy resulting from breast cancer, including all stages of reconstructive surgery on the non-diseased breast to establish symmetry and costs of any prostheses.[33-22-135].

Nebraska:

Requires coverage for medical and surgical benefits for mastectomy and for all stages of reconstruction of the breast after a mastectomy has been performed and reconstruction of the other breast to produce a symmetrical appearance. The measure also requires coverage for prostheses and physical complications of mastectomy. [44-797].

Nevada:

Covers at least two prosthetic devices and reconstructive surgery incident to mastectomy, including surgery to reestablish symmetry. [NRS 608.157]

New Hampshire:

Covers breast reconstruction, including surgery and reconstruction of the other breast to produce asymmetrical appearance, in the manner chosen by the patient and physician. [417-D:2-b].

New Jersey:

Covers reconstructive breast surgery, including coverage to achieve and restore symmetry, and provides benefits for prostheses. [17B:26-2.1a.]

New York:

Covers breast reconstruction following mastectomy, including reconstruction on a healthy breast required to achieve reasonable symmetry, in the manner determined by the attending physician and the patient to be appropriate. [§3221].

North Carolina:

Provides coverage for reconstructive breast surgery, including all stages and revisions of surgery performed on a non-diseased breast to establish symmetry, and reconstruction of the nipple/areolar complex without regard to the lapse of time between mastectomy and reconstruction, as well as coverage for prostheses and physical complications in all stages of mastectomy, including lymph ademas. [§58-51-62]

North Dakota:

Specifies that health insurance policies may not be issued or renewed in the state unless they provide the benefit provisions of the 1998 Federal Women's Health and Cancer Rights Act. [26.1-36-09.11]

Oklahoma:

Covers reconstructive breast surgery performed as a result of a partial or total mastectomy, including all stages of reconstructive surgery performed within 2 years on a non-diseased breast to establish symmetry. [§36-6060.5.(D)]

Pennsylvania:

Covers prosthetic devices and breast reconstruction, including surgery on the opposite breast to achievesymmetry, within six years of the mastectomy date. Additional legislation adds language consistent withfederal law.

Rhode Island:

Covers prosthetic devices and reconstructive surgery to restore and achieve symmetry incident to a mastectomy. Surgery must be performed within 18 months of the original mastectomy. [§27-18-39]

South Carolina:

Covers prosthetic devices and breast reconstruction, including the non-diseased breast, if determined medically necessary by the patient and attending physician with the approval of the insurer. [38-71-130]

Tennessee:

Covers all stages of reconstruction for the diseased breast, excluding lumpectomy, and procedures to restore and achieve symmetry between the breasts, in the manner chosen by the patient and physician, within five years of the reconstructive surgery on the diseased breast. [56-7-2507]

Texas:

Covers reconstruction of the breast incident to mastectomy, including procedures to restore and achievesymmetry, for contracts delivered, issued for delivery or renewed on or after Jan. 1, 1998. 1999amendment conforms statute to federal law. [§1357.004]

Utah:

Follows the example of the federal statute by requiring coverage for medical and surgical benefits for mastectomy and for all stages of reconstruction of the breast after a mastectomy has been performed and reconstruction of the other breast to produce a symmetrical appearance. The measure also requires coverage for prostheses and physical complications of mastectomy. [31A-22-630]

Virginia:

Covers reconstructive breast surgery performed coincident with a mastectomy performed for breast cancer or following the mastectomy, and surgery performed to reestablish symmetry between the two breasts. [§38.2-3418.4]

Washington:

Covers reconstructive breast surgery if mastectomy resulted from disease, illness or injury, includes surgery to reestablish symmetry. [48.46.280]

West Virginia:

Includes coverage for reconstruction of the breast on which mastectomy was performed and the opposite breast for symmetry; also provides coverage for prosthesis and complications as determined in consultation with attending physician and patient. [§33-16-3]

Wisconsin:

Covers breast reconstruction of the affected tissue incident to mastectomy and specifies that such surgery is not considered cosmetic. [149.14(4)(a)]