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    Quick Guide to Insurance Coverage for Items to Manage Side Effects & Reconstruction

    In Triage Cancer's free Quick Guide to Insurance Coverage for Items to Manage Side Effects & Reconstruction, you'll learn about wigs , mastectomy bras and breast prostheses , breast reconstructio n, lymphedema compression garments , and manual lymphatic drainage ,  and whether or not these items are covered by different types of health insurance.

    During the course of cancer treatment, you may find that you need items that help address side effects from treatment, such as hair loss and lymphedema. Lymphedema is the build-up of fluid in soft body tissues when your lymph system is damaged or blocked. Some cancer-related surgeries may cause damage to your lymph system and lead to lymphedema.

    You may also decide that you want reconstructive surgery and/or prostheses after cancer-related surgery. This Quick Guide covers some common items needed after a cancer diagnosis and whether or not those items are covered by different types of insurance.

    Wigs

    • Some private insurance plans (e.g., individual or employer-sponsored plans) cover wigs for medically-induced hair loss under the classification of “durable medical goods.” Tip: get a prescription for a “cranial prosthesis.” Note: some insurance companies specifically list wigs as an excluded benefit. If your plan does cover the wig, you will likely still be responsible for out-of-pocket costs (i.e., a co-pay or co-insurance amount). Check your plan’s summary of benefits and coverage for details.
    • MedicarePart B does not cover wigs for hair loss due to cancer treatment.
    • Medicaiddoes not cover wigs in any state.
    • TRICAREand VA Health both cover one wig per the lifetime of a beneficiary, for hair loss that occurs due to cancer treatment. Note: this does not include wig supplies or maintenance (e.g., wig cap, comb, glue, etc.).

    Mastectomy Bras & Breast Prostheses

    • Individual and employer-sponsored private insurance plansmust cover mastectomy bras and external breast prostheses under the classification of “durable medical equipment,” if covered by The Women's Health and Cancer Rights Act ofWomen's Health and Cancer Rights Act of 1998, WHCRA1998 (WHCRA).
      • WHCRA is a federal law that protects patients who have a mastectomy (or lumpectomy) due to a breast cancer diagnosis, by requiring private insurance plans that covered the mastectomy to also cover:
        • All stages of reconstruction of the breast on which the mastectomy has been performed
        • Surgery and reconstruction of the other breast to develop a symmetrical appearance
        • Prostheses and treatment of physical complications of all stages of the mastectomy, including lymphedema
    • Medicaidcoverage of mastectomy bras and breast prostheses varies by state. Contact your state Medicaid program for details.
    • MedicarePart B covers mastectomy bras and external breast prostheses under the classification of “durable medical equipment.”
    • TRICAREcovers two initial mastectomy bras and two replacement bras per calendar year. Breast prostheses are limited to the first initial prosthesis or set of prostheses. Replacements are subject to medical review.
    • VA Healthcovers external breast prostheses and bras following a mastectomy as medical supply items.
      • A maximum of seven surgical bras are covered on an annual basis.
      • One replacement external silicone breast prosthesis is covered every 24 months.

    Breast Reconstruction

    • Individual and employer-sponsored private insuranceplans must cover all stages of reconstruction of the breast on which a mastectomy has been performed and surgery and reconstruction of the other breast to develop a symmetrical appearance. See WHCRA above.
    • MedicarePart A covers surgically implanted breast prostheses following a mastectomy if the surgery is in an inpatient setting. Part B covers the surgery in an outpatient setting.
    • Medicaidcoverage of breast reconstruction surgery varies by state. Contact your state Medicaid program for details.
    • Both TRICAREand VA Health plans cover breast reconstruction surgery after a mastectomy, due to a breast cancer diagnosis.

    Lymphedema Compression Garments

    • Some private insurance plans cover lymphedema compression garments for cancer patients.
      • These state laws require that private insurance plans either directly or indirectly provide coverage for lymphedema compression garments and supplies:
      • Maryland and Virginia require that health plans subject to state regulation cover lymphedema treatment, including compression garments.
      • California, Massachusetts, and North Carolina require that health insurers pay some of the costs of compression garments
    • MedicarePart B covers gradient compression garments if you’ve been diagnosed with lymphedema and your doctor prescribes them.
    • 47 states and the District of Columbia fully or partially cover compression supplies under Medicaid.
    • TRICAREcovers medical supplies and dressings necessary for a medical condition, including lymphedema compression garments.
    • VA Healthcovers compression garments under orthotic devices.

    Manual Lymphatic Drainage

    • Manual lymphatic drainage coverage varies by private insurance plan, so it is important to check the specific details of your coverage.
    • Medicaredoes cover manual lymphatic drainage for lymphedema.
    • Medicaidin most states covers medically necessary treatments performed by a licensed massage therapist, but coverage varies. Contact your state Medicaid program for details.
    • TRICAREand VA Health do not specifically cover manual lymphatic drainage. However, some VA programs have a lymphedema management program for veterans

    Visit CancerFinances.org for information on financial assistance resources, to help cover the costs of these items. For more information about health insurance coverage, visit TriageCancer.org/HealthInsurance .

    Last reviewed for updates: 02/2024

    Disclaimer: This handout is intended to provide general information on the topics presented. It is provided with the understanding that Triage Cancer is not engaged in rendering any legal, medical, or professional services by its publication or distribution. Although this content was reviewed by a professional, it should not be used as a substitute for professional services. © Triage Cancer 2024

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