A Closer Look At The WHCRA 

A Closer Look At The WHCRA 

The Women’s Health and Cancer Rights provides mandated insurance coverage protection for women whose breast cancer leads them to undergo a breast reconstruction surgery following a mastectomy. In place since 1998, the bill applies to individual plans as well as employer provided group health plans, and under the rules of the WHCRA, insurance is required to cover numerous aspects of the mastectomy and breast reconstruction. In particular, the following must be covered:

  • Reconstruction of the breast that has had a mastectomy preformed on it
  • Surgery or reconstruction of the breast that wasn’t affected in order to produce symmetry 
  • Breast implants or prostheses to help restructure the breast following a mastectomy
  • Any physical complications that might occur at any stage of the mastectomy

In other words, the WHCRA is designed to help ensure that women who are facing breast cancer are able to choose a mastectomy without fear of being left with uneven breasts or with other similar issues. After the mastectomy, reconstructive surgeries must be included in their insurance coverage. 

However, the act doesn’t specifically mention that lumpectomies are covered. This can be an issue for some since a lumpectomy could disfigure a breast or make the breasts appear unsymmetrical. Since it’s not a mastectomy in the larger definition of the term, is reconstructive surgery for lumpectomies included in the WHCRA? 

The answer here is that it depends. Many states will include lumpectomies in the WHCRA since they are considered to be ‘partial mastectomies’. California is one such example of this, as detailed in SB255 which can be reviewed here: http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml;jsessionid=c22ab6d2951f1b245437199571a5

In the case of a lumpectomy, the best course of action is to submit the procedure to insurance companies even if it doesn’t outright say that lumpectomies are covered. If the claim is denied, it can be appealed. In fact, there are external independent review organizations in all states thanks to the health care reform laws that have been passed over the last few years. If these review boards determine that a lumpectomy and the subsequent reconstruction is medically necessary, it’s highly likely that it will be considered a partial mastectomy and covered by a policy. 

One final thing to understand is that the WHCRA doesn’t require all health insurance policies to cover mastectomies at all. However, if an insurance plan includes mastectomies in its coverage umbrella, then that plan will likely be required to follow the WHCRA guidelines on the subject. 

Patients and providers do have rights when a  mastectomy, lumpectomy, or a breast reconstruction surgery following either of them is necessary. Even if it appears as though a procedure may not be part of a patient’s insurance plan, there is still a chance that it could be. The WHCRA may provide the patient and the provider with protection they didn’t even know they had. 

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