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Insurance Coverage Required for Post-Mastectomy Breast Reconstruction
If Mastectomy Is Covered |
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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]
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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]
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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. 300gg-52 regarding coverage for reconstructive
surgery following mastectomies. |
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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] |
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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)]
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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)] |
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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] |
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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] |
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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] |
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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] |
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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] |
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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]
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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] |
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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)] |
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Maryland: |
Requires coverage for reconstructive surgery resulting from a
mastectomy, including surgery performed on a non-diseased breast to
establish symmetry. [§15-815] |
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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] |
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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]. |
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Missouri: |
Covers prosthetic devices and reconstructive surgery necessary to
achieve symmetry, as recommended by the oncologist or primary care
physician. [376.1209] |
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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]. |
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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].
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Nevada: |
Covers at least two prosthetic devices and reconstructive surgery
incident to mastectomy, including surgery to reestablish symmetry. [NRS
608.157] |
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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].
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New Jersey: |
Covers reconstructive breast surgery, including coverage to achieve and
restore symmetry, and provides benefits for prostheses.
[17B:26-2.1a.] |
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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]. |
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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] |
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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] |
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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)] |
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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. |
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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] |
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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] |
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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] |
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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]
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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]
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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] |
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Washington: |
Covers reconstructive breast surgery if mastectomy resulted from
disease, illness or injury, includes surgery to reestablish symmetry.
[48.46.280] |
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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]
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Wisconsin: |
Covers breast reconstruction of the affected tissue incident to
mastectomy and specifies that such surgery is not considered cosmetic.
[149.14(4)(a)]
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