Coverage for prophylactic mastectomy — maybe, maybe not

My aunt died of breast cancer at age 42, and my mother has had a mastectomy.  Now my sister has been diagnosed with a suspicious lump.  I’m considering getting a mastectomy, even though I have not had any problems yet.  My doctor is willing to give me a referral to a surgeon.  Will my health insurance cover it?

Better Safe Than Sorry

Dear Better Safe Than Sorry,

Health insurance will generally cover services that are considered “medically necessary”. A prophylactic mastectomy can be considered medically necessary, in some cases. Your insurer may have specific criteria for you to meet. For example, they may want to know your risk for breast cancer, or family history. You certainly seem to have some family history of the disease.  That may not be enough to make the surgery covered by your plan.

Call your insurer, or ask your surgeon to contact them for you.   You can find out whether you will qualify for any benefits.  You can also know in advance how much your plan will pay for the surgery and how much you have to pay.

Linda Riddell

About Linda Riddell

A published author and health policy analyst with 25 years’ experience, Linda Riddell's goal is to alleviate the widespread ailment of not knowing what your health plan can do for you.