Insurance Coverage


As a breast reconstruction patient, you are about to encounter numerous doctor, hospital, pathology, and anesthesia bills. Remember: Breast reconstruction is a long process that occurs in stages. One of the most common questions among breast cancer patients is, “Will my health insurance cover this?” In the vast majority of cases, the answer is “Yes.”

While insurance coverage varies on a patient-by-patient basis, some elements are fairly standard. Breast reconstruction is covered as long as the mastectomy is covered (and the mastectomy is always covered if it is performed due to the presence of breast cancer). Breast reconstruction after prophylactic (preventive) mastectomy is also usually covered, as long as the patient is deemed high-risk for breast cancer (significant family history of breast cancer, or BRCA gene-positive).

On October 21, 1998, the Women’s Health and Cancer Rights Act of 1998 became effective as part of the 1999 Omnibus Consolidated and Emergency Supplemental Appropriation Act. This new federal law requires group health plans and individual health policies that provide coverage for mastectomies to also provide coverage for breast reconstruction in connection with mastectomy.

In accordance with the Women’s Health and Cancer Rights Act of 1998, members receiving mastectomy-related services are entitled to the following benefits:

  • Reconstruction of the breast on which the mastectomy has been performed
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance
  • Treatment of physical complications at all stages of the mastectomy, including lymphedema

This coverage will be provided in a manner determined in consultation with the attending physician and the patient. These benefits are subject to any deductible or co-insurance requirements that may apply to your coverage.

Insurance companies are mandated by federal law to cover patients’ procedure of choice in all cases of cancer patients who have had mastectomies, as well as surgery on the opposite breast to achieve symmetry. Dr. Sadeghi is an in-network provider with most major US insurance providers.

Here are some helpful answers to some of the most frequently asked questions.

What Is an In-Network or Out-of-Network Provider?

An in-network provider is a physician or practice that has signed an agreement with your insurance carrier to accept a specific fee for services provided. An out-of-network provider is a physician or practice that does NOT have a signed agreement with your carrier.

Out-of-network providers are not required to “write off” any monies for services rendered, and you may be responsible for any dollar amount not paid by your **It is important to know whether your physician is considered in-network or out-of-network for your insurance plan. Dr Sadeghi is considered in-network for all major U.S. insurance carriers.


What Is a Global Period?

A global period is a specific period of time (generally 90 days after a surgery) during which the patient receives follow-up care and post-operative visits without billing the insurance company. Patients must wait until their global period is complete prior to proceeding with the next stage of their breast reconstruction. Global periods are federally mandated and cannot be


What Is Balance Billing?

Due to shrinking insurance reimbursements to physicians, some DIEP flap surgeons set their fee and ask the patient to pay the remaining amount that the insurance company will not cover (i.e., the difference between the doctor’s fee and the allowable). This process is known as “balance billing,” and can add tens of thousands of dollars to the patient’s final bill, and is in addition to the out-of-pocket expenses described above.

The Aesthetic & Reconstructive Breast Center does not balance-bill our patients..


What Is an Allowable?

An allowable is an agreed-upon or contracted rate between your carrier and provider for a specific service. This is what the insurance company (carrier) pays the doctor.


What Is an Out-of-Pocket Maximum? ​And, how do I reach that?

An out-of-pocket maximum is a specific dollar amount that a patient has to pay per calendar year. Patients reach their out-of-pocket maximum through their co-insurance payments. For example, if you have a $1,000 out-of-pocket maximum and an 80%/20% plan, you will pay 20% of all allowed charges until you have paid $1,000. Once you reach your out-of-pocket maximum, your carrier will begin covering all services at 100%. Remember, co-pays are not included in out-of-pocket maximums.


What Is Co-Insurance?

Co-insurance is the amount shared by you and your insurance carrier for medical expenses. For example, in an 80%/20% co-insurance plan, the insurance carrier pays 80% of the allowed charges and the patient pays 20% of the allowed charges. Please remember that your insurance company begin paying for medical expenses until your deductible has been met.


What Is a Co-Pay?

A co-pay is a fixed dollar amount that is to be paid by the patient each time the patient is seen for medical services. Co-pays do not apply toward a patient’s deductible.



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