- Surgeries, Post-bariatric, Breasts
Mammoplasty through insurance
- December 2, 2022
- By Fernando Amato
When is it possible to use insurance for breast surgeries?
In addition to surgeries related to the diagnosis and treatment of breast cancer. It is possible to obtain some coverage for mammoplasty surgeries through insurance when the patient has functional alterations or diseases caused by changes in the volume and shape of the breast, such as:
Postural changes, leading to back pain, or even changes caused by friction of the breasts with inflammation and skin infection.
What does the National Health Agency (ANS) Opinion state?
The procedure MASTECTOMY OR MAMMOPLASTY FOR CORRECTION OF MAMMARY HYPERTROPHY (procedure performed to correct breast gigantism) is not included in the List of Procedures and Health Events. For this reason, it does not have mandatory coverage.
How is it stated in the Opinion of the National Health Agency (ANS)?
TECHNICAL OPINION Nº 19/GEAS/GGRAS/DIPRO/2021
COVERAGE: BREAST AND LYMPHATIC SYSTEM (MASTECTOMY / MAMMOPLASTY)
The List of Procedures and Health Events, currently regulated by RN n.º 465/2021, effective from 01/04/2021, establishes the mandatory healthcare coverage to be guaranteed in private health assistance plans contracted from January 1, 1999, and in those adapted, as provided in article 35 of Law n.º 9.656, of June 3, 1998, respecting, in all cases, the contracted healthcare segments.
The procedure MASTECTOMY is listed in Annex I of RN n.º 465/2021, and must be mandatorily covered by new plans and adapted old plans, of hospital segmentation (with or without obstetrics) and reference plans, as indicated by the treating physician.
It should be clarified that there are several procedures for the surgical treatment of breast tumors or for patients who qualify as high risk for breast cancer according to the established Utilization Guidelines. These procedures have varied descriptions. Namely: Radical or modified radical mastectomy – any technique; Simple mastectomy; Double mastectomy; Skin-sparing mastectomy; Nipple-sparing mastectomy; Risk-reducing mastectomy; Subcutaneous mastectomy; Adenomastectomy and Lumpectomy (Breast-conserving surgery; Partial mastectomy; Segmental mastectomy; Tumorectomy, Sectorectomy; Wide excision; Segmental resection and Quadrantectomy), among others.
It should also be noted that the above procedures may or may not be accompanied by axillary lymphadenectomy and removal/resection of the sentinel lymph node. Preserving the pectoral muscles and their aponeuroses, skin, and areola-nipple complex.
MASTECTOMY surgery
MASTECTOMY surgery also has mandatory coverage when indicated by the treating physician in the following situations: 2 Published on 01/04/2021
1. genetic examination indicates the probability of developing breast cancer, according to Utilization Guidelines;
2. opposite breast in a patient with cancer diagnosed in one breast;
3. complementary procedure to the sex reassignment process, according to specific Technical Opinion (TECHNICAL OPINION Nº 26/GEAS/GGRAS/DIPRO/2021).
Article 10-A of Law nº 9.656/1998 establishes that health plan operators, through their network of accredited units, must provide reconstructive plastic surgery service for the breast. Using all necessary means and techniques for the treatment of mutilation resulting from the use of cancer treatment techniques.
The modalities of breast plastic surgery, whether or not associated with the use of prostheses and/or expanders for breast reconstruction, contained in the aforementioned List. These will have mandatory coverage by the mentioned health plans when indicated by the treating physician, for beneficiaries with:
1) diagnosis of breast cancer;
2) probability of developing breast cancer according to genetic testing;
3) traumatic lesions and tumors in general (when their removal, even for investigative purposes, mutilates the breast).
Reconstruction of the opposite breast
It should be noted that the reconstruction of the opposite breast is also mandatorily covered and is included in the procedure MASTECTOMY IN THE OPPOSITE BREAST AFTER CONTRALATERAL RECONSTRUCTION IN CASES OF TRAUMATIC LESIONS AND TUMORS, indicated for beneficiaries with a confirmed diagnosis in one breast, when the treating physician deems the surgery of the other breast necessary, even if it is still healthy.
On the other hand, the procedure MASTECTOMY OR MAMMOPLASTY FOR CORRECTION OF MAMMARY HYPERTROPHY (procedure performed to correct breast gigantism). It is not included in the List of Procedures and Health Events. For this reason, it does not have mandatory coverage.
In supplementary health, the incorporation of new health technologies, regulated by RN n.º 439/2018, as well as the definition of rules for their use. It is defined through successive cycles of updating the List of Procedures and Health Events (Available at: http://www.ans.gov.br/participacao-da-sociedade/atualizacao-do-rol-de-procedimentos).
Finally, it is important to emphasize that, in the case of old, unadapted plans (plans contracted until 01/01/1999 and not adjusted to Law n.º 9.656/1998, in the terms of its art. 35), coverage for the procedure under analysis will only be due if there is a provision to that effect in the respective contractual instrument.
Related articles
Agendar consulta
Precisa de orientação personalizada?
Marque uma avaliação com o Dr. Fernando Amato e tire as suas dúvidas sobre cirurgia plástica.
Falar no WhatsApp
