Cigna Breast Reconstruction Policy

One of the worst policies in the business is Cigna’s approach to breast reconstruction.

Once a breast is partially or completely removed due to cancer (mastectomy), breast implants reconstruct the breast’s contour. There are various implant options.

On occasion, a mastectomy and implant are performed simultaneously. Nonetheless, it’s common to require two operations. A tissue expander will initially be inserted beneath the skin by the physician. To assist extend the skin, saline (or air) is progressively supplied to the expander. This could take a while. The expander is removed and an implant is inserted once the correct size has been achieved. Later development produces the nipple and the darker area around it (areola).

This post also discusses cigna gynecomastia coverage and how to get cigna to approve breast reduction.

Breast reconstruction is surgery to recreate breasts after mastectomy or lumpectomy. Sometimes reconstruction takes several surgeries. There are many breast reconstruction techniques. Some use silicone or saline breast implants. Other techniques use a flap of tissue from your body (such as tissue from the lower belly).

Breast reconstruction can happen right after breast cancer surgery (immediate reconstruction). Or it can happen months or years later (delayed reconstruction). You may have surgery to reconstruct both breasts. Or your provider may replace one breast and reshape it to match the other. Your provider may recommend multiple surgeries over several stages.

Some people choose to have breast reconstruction after a mastectomy, but many don’t. The decision to have breast reconstruction is very personal.

What are the types of breast reconstruction surgery?

There are two main types of breast reconstruction surgery after mastectomies.

Flap reconstruction

In flap reconstruction, your surgeon takes tissue from your own body (autologous tissue) and uses it to form a breast. Usually, they take the tissue from the lower abdomen (belly). But it can also come from your thigh, back or bottom.

Your surgeon may remove fat, skin, blood vessels and muscle from these parts of your body to form a new breast. Healthcare providers call this tissue a flap. Sometimes, surgeons move a flap through your body (pedicled flap). This way the flap retains its own blood supply. Or they may detach the flap from its blood supply (free flap) and attach it to blood vessels in your chest.

The types of flap reconstruction include:

DIEP flap: Your provider takes skin, fat and blood vessels from the lower belly. A DIEP flap does not remove the underlying abdominal (belly) muscle.
TRAM flap: Your provider removes skin, fat, blood vessels and muscle from the lower belly.
Latissimus dorsi (LD) flap: Providers remove tissue and muscle from the back. They transplant the LD flap (still connected to its own blood supply) through the back to the breast area.
IGAP flap: For this procedure, tissue comes from your butt. Muscle isn’t used in this procedure.
SGAP flap: This technique also removes tissue (not muscle) from your butt. It uses a different group of blood vessels than the IGAP flap procedure.
PAP flap: Your surgeon removes tissue from the inner and back of your thigh and uses it to form a breast. This procedure does not transplant muscle from your thigh.
TUG flap: Similar to a PAP flap, this technique uses tissue from your thigh. A TUG flap transplants muscle as well as tissue.
SIEA flap (or SIEP flap): This procedure is like a DIEP flap, but it uses different blood vessels. Providers don’t use this technique as often. Few people have the blood vessels necessary for the surgery to be successful.

Implant reconstruction

In implant reconstruction, surgeons use saline or silicone implants to recreate breast tissue. Sometimes surgeons use a combination of implants and tissue from your body. Implant reconstruction can happen along with a mastectomy. Or you may choose to have this procedure after a mastectomy.

The types of implant reconstruction are:

Under the chest muscle: Your surgeon lifts up the chest muscle and places the implant underneath it.
Above the chest muscle: Your surgeon places the implant on top of the chest muscle. You may not need as much recovery time because your chest muscle remains in place.
Implant with tissue expander: Your surgeon places an expander under your skin. About once per week, you or your healthcare provider fills the expander with saline. Your skin gradually expands (stretches). Your surgeon will place the implant once your skin has expanded enough to cover it.

Oncoplastic reconstruction after lumpectomy

If you are a candidate for lumpectomy, you may benefit from oncoplastic reconstruction. Your oncologic breast surgeon will help you know if you are a candidate for breast conservation. However, you’ll require radiation when a lumpectomy is performed.

In oncoplastic reconstruction, surgeons use the techniques of breast reduction or breast lift at the same time as the lumpectomy. The breast reduction or breast lift helps to fill in the defect created by the lumpectomy and improves the breast shape. You’ll need a breast reduction or lift on the other breast for symmetry.

Can a nipple be reconstructed?

Some types of mastectomy leave the nipple and areola in place (nipple-sparing mastectomy). The areola is the dark skin surrounding the nipple. If necessary, providers can create a new nipple. They do this by transferring skin from another part of your body (skin graft) or local skin on the breast to shape into a nipple.

Some people choose to get a 3D tattoo of an areola after nipple reconstruction. Specially trained tattoo artists create realistic images of an areola.

How do I know what type of breast reconstruction surgery to get?

Your provider will recommend the most appropriate technique for you based on:

Your age, overall health and lifestyle.
The kind of mastectomy or lumpectomy you had and how much tissue remains.
Whether you need additional treatments for breast cancer (such as chemotherapy or radiation).
Past surgeries you’ve had that may make it difficult or impossible to take a flap from your belly. One example is abdominal surgery.
Your goals and desired appearance.

What does breast reconstruction treat?

Most often, breast reconstruction happens after surgery to treat or prevent breast cancer. Providers use it to reshape breasts and rebuild damaged or missing tissue. They may also perform this surgery to restore symmetry. This means they make both breasts the same size and shape. Less commonly, providers reconstruct breast tissue that results from congenital abnormalities (birth defects).

After a mastectomy, it’s normal to mourn the loss of your breast. Breast reconstruction surgery helps many people manage these strong emotions and move forward.

PROCEDURE DETAILS

What happens before breast reconstruction surgery?

Breast reconstruction happens after a mastectomy or lumpectomy. If you have breast cancer, you may also need chemotherapy or radiation before breast reconstruction surgery. Your surgeon will ask you about your goals and discuss your surgical options with you.

First, your surgeon will conduct a comprehensive examination. They will measure and take photographs of your breasts. Tell your provider about your health, medications you take and any surgeries you’ve had. Your provider may ask you to stop taking certain medications before the procedure.

What happens during breast reconstruction surgery?

A surgeon will perform your breast reconstruction surgery in a hospital. Your provider gives you anesthesia, so you’ll be asleep and you won’t feel any pain during the surgery. If you’re having a mastectomy or lumpectomy, your surgeon will do that procedure first.

While you’re still asleep, your surgeon performs the breast reconstruction. If you’re getting implant reconstruction, they place the implant in your chest. If you’re having a flap procedure, they take tissue from one part of your body, form and place the new breast.

During surgery, your provider may insert a drain (a thin tube) under your skin. One end of the tube sticks out from your chest. The tube drains fluid and blood as you recover. Your provider will remove the tubes when you don’t need them anymore.

What happens after breast reconstruction surgery?

Your team of providers will watch you to ensure you’re healing. You may wear a surgical bra. As your breasts heal, the bra supports your breasts and reduces swelling. When it’s time to go home, your provider will give you instructions detailing how to care for yourself.

After surgery, your doctor will assist you in managing your pain. They might suggest painkillers on prescription or off-label. When taking medication, carefully adhere to your doctor’s directions.

If you had reconstruction on one breast, you may need more surgery to make your breasts match. This may include breast reduction surgery or breast augmentation.

RISKS / BENEFITS

What are the advantages of breast reconstruction surgery?

Breast reconstruction surgery can improve self-confidence after a mastectomy or lumpectomy. After breast reconstruction, many people feel better about how their clothes fit. They may also feel more comfortable wearing a swimsuit.

Many people choose not to have breast reconstruction after a mastectomy. Instead, they wear a breast form (prosthesis) inside a special bra. They may also choose to “go flat” and not wear prosthetic breasts. The decision is very personal and varies from person to person.

What are the risks or complications of breast reconstruction surgery?

As with any surgical procedure, risks of breast reconstruction include infection and bleeding. Results vary depending on the type of procedure and how much tissue remained after breast cancer surgery and radiation.

After surgery, you’ll probably have little or no sensation in your newly reconstructed breasts. Over time, you may regain some sensation in the skin. But it won’t feel like it did before.

Complications of breast reconstruction surgery may include:

Blood clots. These may be more likely to happen after some types of flap reconstruction surgeries.
Breasts that are a different size or shape. One may feel more firm than the other. The nipples and areolas may not be symmetrical.
Bruising or scarring around the reconstructed breasts. All breast reconstruction surgeries leave scars. They may fade over time.
Fat necrosis. Death of the transplanted tissue after flap surgery.
Problems with the implants (for implant reconstruction). These problems can include wrinkling, rippling and ruptures (tears) in the implant.
Weakness, pain or sensitivity at the donor site after a flap reconstruction procedure. Donor sites may include the lower belly, thigh, back or bottom.

Do implants carry extra risk?

A uncommon form of cancer known as anaplastic large cell lymphoma (ALCL) may be made more likely by certain implants. The majority of these implants are no longer available in the US market. Inquire with your doctor about the possibility of getting ALCL following implant surgery.

RECOVERY AND OUTLOOK

When can I go back to my usual activities after breast reconstruction surgery?

Everyone recovers from surgery differently. Your recovery time depends on several factors. These include your overall health and the type of procedure you had.

You will need to avoid lifting, exercising or doing some activities for a while to give your body time to heal. Talk to your provider about when you can get back to the activities you enjoy.

Cancer can return after breast reconstruction surgery. See your provider for regular checkups. If you had one breast reconstructed, you’ll need regular mammograms on the other breast to check for cancer.

WHEN TO CALL THE DOCTOR

When should I see my healthcare provider about breast reconstruction surgery?

Call your provider right away if you have:

Signs of infection, such as fever.
Severe pain or pain that doesn’t get better with medications.
Bleeding or fluid (pus) coming from the incisions.
Changes in color on the breast or near the incisions.

A note from Cleveland Clinic

Breast reconstruction surgery can improve self-confidence and body image after a mastectomy or lumpectomy. The decision to get breast reconstruction is very personal. If you decide to get this surgery, talk to your provider about the technique that’s right for you. Be honest and open about your goals, lifestyle and desired appearance. You may need more than one surgery over several months. Follow your provider’s instructions during recovery. Call them right away if you have severe pain or signs of infection.

Cigna Gynecomastia Coverage

Coverage for the surgical treatment of gynecomastia is dependent on benefit plan language, may be
subject to the provisions of a cosmetic and/or reconstructive surgery benefit, and may be governed by
state mandates. Under many benefit plans, the surgical treatment of gynecomastia is not covered when
performed solely for the purpose of altering appearance or self-esteem or to treat psychological
symptomatology or psychosocial complaints related to one’s appearance. In addition, gynecomastia
surgery is specifically excluded under some benefit plans. Please refer to the applicable benefit plan
document to determine benefit availability and terms, conditions and limitations of coverage.
If coverage for the surgical treatment of gynecomastia is available, the following conditions of coverage
apply.
Cigna covers the surgical treatment of gynecomastia as medically necessary for EITHER of the
following conditions:
• Klinefelter’s syndrome
• Either pubertal (adolescent) onset gynecomastia that has persisted for at least two years OR post
pubertal-onset gynecomastia that has persisted for one year, when ALL of the following criteria are met:
 Glandular breast tissue confirming true gynecomastia is documented on physical exam and/or
mammography.
 The gynecomastia is classified as Grade II, III or IV per the American Society of Plastic Surgeons
classification.
 The condition is associated with persistent breast pain, despite the use of analgesics.

When medically necessary, the use of medications and chemicals that have been identified as having the potential to cause gynecomastia has been stopped for at least a year.
 Even after any underlying problems have been treated, the gynecomastia still exists.
 By performing the necessary laboratory tests (e.g., measuring levels of thyroid stimulating hormone [TSH], estradiol, prolactin, testosterone, and/or luteinizing hormone [LH]), hormonal causes like hyperthyroidism, estrogen excess, prolactinomas, and hypogonadism have been ruled out and, if present, have been treated for at least a year before surgery has been considered.
Because it is not deemed medically necessary, Cigna does not pay surgical therapy for gynecomastia for ANY other reason.
Because each is deemed cosmetic in nature and not medically necessary, Cigna does NOT cover surgical treatment of gynecomastia for EITHER of the following indications: • when carried out solely to enhance the appearance of the male breast or to change the contours of the chest wall • when carried out solely to treat psychological or psychosocial complaints
Because suction lipectomy and ultrasonically assisted suction lipectomy (liposuction) are not yet demonstrated to be effective in treating gynecomastia, Cigna does not cover them as a sole mode of treatment.
Basic Background
The growth of glandular breast tissue causes gynecomastia, a benign expansion of the male breast. 50–70% of boys experience the syndrome during puberty; between 30% and 65% of men develop palpable breast tissue (Narula and Carlson, 2007). A painful, sensitive mass beneath the areola or a painless, gradual expansion of the breast may afflict one or both breasts. Gynecomastia typically goes away within months after the root cause is found and treated; pubertal gynecomastia typically goes away on its own.

How To Get Cigna To Approve Breast Reduction

There are several steps you need to take to get insurance to cover breast reduction surgery, including:

Pre-authorization

If you have a comprehensive insurance plan that includes coverage for a breast reduction, you’ll need to provide documentation to prove that it is medically necessary to get pre-authorization.

You’ll need to provide medical records from licensed physicians demonstrating that you have experienced physical complaints and attempted conservative interventions before you can schedule your surgery. These documents may need to date back 6 to 12 months.

Some of the doctors you may need to obtain notes from include your OB/GYN, primary care doctor, orthopedic surgeon, or physical therapist. Most plastic surgeons also recommend that you provide documentation of any complementary alternative medicine (CAM) therapies, such as an acupuncturist or chiropractor.

At your initial breast reduction consultation, your doctor may take photographs of your pre-operative breasts as evidence for the insurance company. They can also provide you with a note documenting the symptoms that lead you to seek a breast reduction.

The documentation is reviewed by a panel of medical professionals that work for the insurance company to assess your medical history and determine if breast reduction surgery is medically necessary in your case.

Initial rejection

According to the AARP, up to 14% of all insurance claims are initially rejected. But that doesn’t mean you can’t get coverage for your breast reduction surgery. You can appeal the rejection. Have your surgeon write a letter to the insurance board explaining why you are a suitable candidate for the surgery. You can also obtain letters of support from other medical professionals to help your case.

Authorization

Once your documentation is accepted, and the insurance company gives their authorization, you can book your breast reduction surgery. Most insurance companies require you to co-pay for a stay at a hospital or medical facility, which can cost from $100-$300.

Cigna Breast Reconstruction Policy