When St. Petersburg, Florida, plastic surgeon, Dr. Alicia Billington, watched a recent episode of Grey’s Anatomy, she never expected to see her advocacy work spotlighted on primetime television.
The episode addressed a stark reality: despite federal protections, breast cancer survivors are routinely having insurance claims denied for reconstructive procedures their doctors recommend.
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Billington’s advocacy caught the attention of her friend Dr. Michael Metzner, a supervising producer for Grey’s Anatomy. When she told him about her patients’ insurance struggles, he brought the issue to the show.
"(It’s) a very important piece of information to put out there, because we’re trying to educate without people knowing that they’re being educated," Metzner told Tampa Bay 28 (1).
Grey’s Anatomy star Jason Winston George also spoke out, featuring Billington’s advocacy video on his Instagram and stating, "The law needs to be modernized to ensure that every woman has access (to) modern breast reconstruction options. It’s that simple."
Now, Billington is hoping an even bigger voice may amplify the cause — pop superstar Taylor Swift, whose mother, Andrea, has battled breast cancer. (Swift even wrote a song about the experience.)
Why federal law doesn’t guarantee coverage, and the out-of-pocket cost
The problem stems from gaps in the Women’s Health and Cancer Rights Act (WHCRA), a federal law passed in 1998 that requires most group insurance plans covering mastectomies to also cover breast reconstruction. So why are patients being denied?
The law has become outdated. Medical technology and surgical techniques have advanced significantly in 27 years, but WHCRA’s language hasn’t kept pace, creating loopholes insurance companies exploit to justify denials.
And the financial burden is substantial. According to The Aesthetic Society, the average cost for breast reconstruction surgery is $6,221 (2), though RealSelf (3) reports complex cases can reach $76,000 without insurance coverage.
Research published in Plastic and Reconstructive Surgery (4) shows median costs for initial surgery (including mastectomy) are approximately $24,623 for tissue expander procedures and $38,019 for autologous reconstruction.
Suffice it to say, the cost can vary greatly.
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New legislation aims to close the gaps
The good news is, work is being done to find a more accessible solution that increases approval rates.
U.S. Representatives Kat Cammack of Florida and Debbie Dingell of Michigan recently introduced bipartisan legislation to modernize WHCRA.
The proposed bill would close insurance loopholes to give breast cancer patients access to the reconstructive care they need, with options aligned with their goals, while ensuring coverage evolves as medical technology advances.
What to do if your claim is denied
Until that change happens, if your insurance company denies coverage, don’t give up. Appeals can be successful when handled properly. Here’s how to prepare:
- Review the appeal steps on Healthcare.gov, so you understand the full process.
- Carefully read and understand the denial letter. Understanding why your claim was denied is crucial. Look for specific reasons cited and note any appeal deadlines.
- Gather supporting documentation. Your plastic surgeon should submit updated scientific information about the standard of care and relevant medical literature. Letters from other treating physicians can strengthen your case.
- Submit your appeal in writing and on time. Put your appeal in writing with delivery confirmation, including treatment records and a letter from your doctor explaining why treatment is medically necessary based on the insurance company’s guidelines.
- Know your appeal rights. Multiple levels of appeal are typically available. External review options exist if internal appeals are exhausted.
- Work with your surgeon’s office. Many plastic surgeons specializing in breast reconstruction have staff trained to advocate with insurers on patients’ behalf.
Financial assistance options
For patients who can’t afford reconstruction surgery, several organizations provide help:
- My Hope Chest has been helping breast cancer survivors access reconstruction surgery for over 20 years, providing financial assistance to uninsured and underinsured survivors.
- The Alliance in Reconstructive Surgery (AiRS) Foundation provides grants to offset breast reconstruction surgery costs.
- FORCE (Facing Our Risk of Cancer Empowered) has more than 50 outreach groups nationwide that offer support, education, advocacy and research to those impacted by hereditary cancer.
- The Plastic Surgery Foundation’s Breast Reconstruction Awareness Fund awards charitable grants of up to $10,000 to U.S.-based tax-exempt public charities that provide breast reconstruction surgery awareness and care.
- The United Breast Cancer Foundation offers financial assistance for breast reconstructive surgery within five years of diagnosis or completing active treatment.
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Article sources
We rely only on vetted sources and credible third-party reporting. For details, see our editorial ethics and guidelines.
Tampa Bay 28 (1); The Aesthetic Society (2); RealSelf.com (3); NLM (4)
This article provides information only and should not be construed as advice. It is provided without warranty of any kind.