Women's Health and Cancer Rights Act and lumpectomy

Hi spc,

Good question! You're right that the Women's Health and Cancer Rights Act (WHCRA) does not specifically mention coverage of lumpectomies, and because of that insurance companies in most states are not required to cover them. But that doesn't mean that you shouldn't try to get the insurance companies to cover the procedure- whether the policy says it covers it or not. If an insurance company denies coverage of reconstruction for lumpectomy, you can appeal it. Appeals usually come in two forms and stages: 1) internal, or through the insurance company and 2) external, through an independent medical review body, available in all states now because of health care reform. If you get to the external appeal stage you can argue that it's medically necessary to have this reconstruction, and that the lumpectomy should be considered a partial mastectomy.

Some states, like California with the recent passage of SB255, (http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml;jsessionid=c22ab6d2951f1b245437199571a5)

require coverage of reconstruction after lumpectomies, and the law considers them partial mastectomies. So it's always worth checking with the department of insurance in your state to see if a state law applies. You can also contact us at the Cancer Legal Resource Center if you want help in accessing this information or other reconstruction or breast cancer- related legal issues. (1-866-THE-CLRC).

Hope this helps!

Best, Laura Riley, Staff Attorney at the Cancer Legal Resource Center

I believe that it IS covered. It is my understanding that deformities left after a lumpectomy are allowed to get reconstruction to get symmetry with the other breast.