diep flap

Will Insurance Cover the Cost of a DIEP Flap Surgery?

According to a 1998 federal law, health insurance plans must offer benefits for post-mastectomy breast reconstruction surgeries, including DIEP Flap and other autologous procedures.  However, the law does not prohibit health insurers from imposing copayments, deductibles, and other restrictions on breast reconstruction procedures.  The end result is that the best health insurance plans will cover nearly the full cost of a DIEP Flap surgery, while many other policies cover only a tiny fraction of the overall costs of the procedure.

In many insurance policies, breast reconstructions performed by an “in-network” surgeon will minimize a patient’s out-of-pocket expenditures.  In-network surgeons are then reimbursed by insurance companies at specially negotiated rates that are generally much lower than the “sticker price” that the surgeon would normally charge.

While these negotiated rates may allow insurers to reduce the costs paid directly by patients, the reimbursement system can actually limit a patient’s in-network options. Since insurance companies typically reimburse surgeons at a flat rate for each procedure—regardless of the type of breast reconstruction chosen by the patient—it is often uneconomical for in-network doctors to offer relatively complex procedures such as DIEP Flaps.   DIEP Flap surgeries can last as long as 12 hours, and it is difficult for a surgeon to perform more than a small handful of DIEP Flap surgeries in any given week.  As a result, many in-network surgeons do not offer DIEP Flap surgeries at all, and patients may only be able to undergo a DIEP Flap surgery with an out-of-network surgeon.

In an ideal world, no patient should have to make medical decisions based on cost, and patients may still wish to consider a DIEP Flap surgery performed by a team of out-of-network surgeons.  In some cases, patients may find that the benefits of an autologous surgery performed by a skilled surgical team may still be worth the additional out-of-pocket expense, depending on the patient’s aesthetic preferences, medical history, and personal financial situation.  Before making a final decision, patients are strongly encouraged to consult carefully with surgeons who perform a full spectrum of breast reconstruction surgeries to determine whether a DIEP Flap procedure provides the most viable long-term option.