Breast Reconstruction Insurance Coverage (including DIEP, SIEA, GAP and TUG Flap Surgery) - State Laws

*** All PRMA plastic surgeons are in-network with most US insurance plans ***

Insurance companies are mandated by federal law to pay for breast reconstruction. Procedures covered include DIEP flap, SIEA flap, GAP flap, TUG flap, TRAM flap and breast implant reconstruction in all breast cancer patients who have had mastectomies (if the mastectomy is covered). Insurance companies must also cover surgery on the opposite breast to achieve reasonable breast symmetry. We have listed the individual State Laws below.

Please find answers to common breast reconstruction insurance-related questions here.

 

 

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 and or unaffected side.
http://www.legislature.state.al.us/

Alaska

Conforms state law to federal standards. States that health care insurers providing medical and surgical benefits for mastectomies must provide coverage for reconstructive surgery following mastectomies.
http://www.legis.state.ak.us

Arizona

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. regulations regarding coverage for reconstructive surgery following mastectomies.

Arkansas

This law provides that all health benefit plans provide coverage for mastectomy surgery shall also provide coverage for reconstruction of the breast.
http://www.arkleg.state.ar.us/assembly/2011/2012F/Pages/Home.aspx

California

Treatment for breast cancer includes coverage for prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy.
http://www.leginfo.ca.gov

Connecticut

Provides coverage 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 create an asymmetrical appearance.
http://search.cga.state.ct.us

Delaware

Coverage available for all stages of reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; and prostheses and physical complications of mastectomy.
http://legis.delaware.gov/

Florida

Covers prosthetic devices and reconstructive surgery after a mastectomy, which includes surgery to reestablish symmetry; surgery must be chosen by the treating physician.
http://www.flsenate.gov

Illinois

Coverage for breast reconstruction in connection with a mastectomy shall include reconstruction of the breast upon which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses devices and treatment for physical complications at all stages of mastectomies.
http://www.ilga.gov

Indiana

Covers prosthetic devices and all stages of reconstructive surgery, in the manner determined by the physician and patient, including reconstruction of the other breast to produce bilateral symmetry.
http://www.in.gov

Kansas

Covers breast reconstruction, including surgery of the unaffected breast to produce a symmetrical appearance, prosthetic devices and physical complications.
http://www.kslegislature.org

Kentucky

Provides coverage for breast reconstruction, including surgery of the other unaffected breast to produce asymmetrical appearance, prosthetic devices and physical complications.
http://www.lrc.ky.gov

Louisiana

Coverage for reconstruction of the breast on which the mastectomy has been performed, provide coverage for reconstruction of the unaffected breast to produce a symmetrical appearance.  Coverage for prosthetic devices and physical complications all stages of mastectomy, including lymphedemas and such coverage shall be in a manner determined necessary by the treating physician and the patient.
http://senate.la.gov/default.asp

Maine

Provides coverage for reconstruction surgery of the breast on which surgery has been performed and covers the unaffected breast to produce a symmetrical appearance if the patient elects reconstruction in a manner chosen by the patient and the treating physician.
http://janus.state.me.us/legis

Maryland

Provides coverage for reconstructive surgery resulting from a mastectomy, including surgery performed on the unaffected breast to establish symmetry.
http://mlis.state.md.us//

Michigan

Covers breast cancer rehabilitative services including reconstructive plastic surgery and physical therapy. Reconstructive surgery and prostheses are covered after the treating physician has certified medical necessity.
http://www.legislature.mi.gov

Minnesota

Covers all reconstructive surgery following injury, sickness or other diseases of the involved part, or congenital defect for an infant. Specifically includes benefits for all stages of reconstruction following mastectomy, including reconstruction of the unaffected 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.
http://www.revisor.leg.state.mn.us

Missouri

Covers prostheses and reconstructive surgery necessary to achieve bilateral symmetry, as recommended by the oncologist or treating physician.
http://www.moga.mo.gov/

Montana

Covers reconstructive surgery following a mastectomy. Includes all stages of reconstructive surgery and non-affected breast to establish symmetry and costs of any prosthetic devices.
http://leg.mt.gov/css/default.asp

Nebraska

Requires coverage for medical benefits for mastectomy and reconstruction of the breast after a mastectomy has been performed and reconstruction of the other breast to produce a bilateral symmetrical appearance. The measure also requires coverage for prosthetic devices and physical complications of mastectomy.
http://nebraskalegislature.gov/

Nevada

Covers at least two prosthetic devices and reconstructive surgery after mastectomy, including surgery to reestablish symmetry.
http://www.leg.state.nv.us

New Hampshire

Covers breast reconstruction, including surgery and reconstruction of the unaffected site to produce asymmetrical appearance, in the manner chosen by the patient and attending physician.
http://www.gencourt.state.nh.us

New Jersey

Covers reconstructive surgery, including coverage to achieve and restore symmetry, and provides benefits for prostheses devices.
http://lis.njleg.state.nj.us

New York

Covers breast reconstruction following mastectomy, including reconstruction on a unaffected breast required to achieve reasonable symmetry, in a manner determined by the treating physician and patient.

North Carolina

Provides coverage for reconstructive surgery. Includes all three stages of reconstruction performed on non-affected breast to establish symmetry. Reconstruction of the nipple/areola complex without regard to the time lapse between mastectomy and reconstruction, as well as coverage for prosthetic and physical complications in all stages of mastectomy, including lymphademas.
http://www.ncleg.net

North Dakota

Requires health insurance policies may not be renewed or issued  in the state unless they provide the benefit provisions of the 1998 Federal Women’s' Health and Cancer Rights Act.
http://www.legis.nd.gov

Oklahoma

Covers reconstructive breast surgery performed as a result of mastectomy, including all stages of reconstructive surgery performed within 2 years on the non-diseased breast to establish symmetry.
http://www2.lsb.state.ok.us

Pennsylvania

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

Rhode Island

Covers prostheses and reconstructive surgery to restore and achieve symmetry after   a mastectomy. Surgery must be performed within 18 months of the original mastectomy.
http://www.rilin.state.ri.us

South Carolina

Covers prostheses and reconstruction, including the non-affected breast, if determined medically necessary by the patient and treating physician with the approval of the insurer.
http://www.scstatehouse.gov/

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 treating physician, within 5 years of the reconstructive surgery on the diseased breast.
http://www.capitol.tn.gov/

Texas

Covers reconstruction of the breast after mastectomy, including procedures to restore and achieve symmetry, for contracts delivered, issued for delivery or renewed on or after Jan. 1, 1998. 1999 amendment conforms statute to federal law.
http://www.capitol.state.tx.us

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.
http://le.utah.gov/

Virginia

Covers reconstructive surgery performed coincident with a mastectomy performed for breast cancer or following the mastectomy, and surgery performed to reestablish symmetry between the two breasts.
http://leg1.state.va.us

Washington

Covers reconstructive breast surgery if mastectomy resulted from disease, infection or injury, includes surgery to reestablish symmetry.
http://search.leg.wa.gov

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 c consultation with treating physician and patient.
http://www.legis.state.wv.us

Wisconsin

Covers breast reconstruction of the affected tissue is incident to mastectomy and specifies that such surgery is not considered cosmetic.
http://folio.legis.state.wi.us

States without published State laws

The following states do not have individual published state laws to our knowledge: Colorado, Georgia, Hawaii, Iowa, Massachusetts, Mississippi, New Mexico, Ohio, Oregon, South Dakota, Vermont, and Wyoming.