- Surgeries, Ex-obese, Breasts
Mammoplasty by health insurance
- December 2, 2022
- By Fernando Amato
When is it possible to use health 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 through health insurance when the patient has functional alterations or diseases caused by changes in breast volume and shape, such as:
Postural changes, leading to back pain, or even changes caused by the friction of the breasts with skin inflammation and infection.
What does the opinion of the National Health Agency (ANS) say?
The procedure MASTECTOMY OR MAMMOPLASTY FOR THE CORRECTION OF MAMMARY HYPERTROPHY (a 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 care plans contracted from January 1, 1999, and in adapted ones, as provided for in article 35 of Law n.º 9.656, of June 3, 1998, always respecting the contracted healthcare segments.
The procedure MASTECTOMY is listed in Annex I of RN n.º 465/2021 and must be obligatorily covered by new plans and adapted old plans, of hospital segmentation (with or without obstetrics) and reference plans, as indicated by the assisting 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 sentinel lymph node removal/resection, preserving the pectoral muscles and their aponeuroses, skin, and nipple-areola complex.
MASTECTOMY surgery
MASTECTOMY surgery also has mandatory coverage when indicated by the assisting physician in the following situations: 2 Published on 01/04/2021
1. genetic testing indicates the probability of developing breast cancer, as per Utilization Guidelines;
2. opposite breast in a patient with cancer diagnosed in one breast;
3. complementary procedure to the transgenderization process, as per 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 of 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 plasty, whether or not associated with the use of prostheses and/or expanders for breast reconstruction, contained in the aforementioned List, will have mandatory coverage by the mentioned health plans when indicated by the assisting 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 of mandatory coverage and is covered by the procedure MAMMOPLASTY ON 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 assisting physician deems surgery on the other breast necessary, even if it is still healthy.
On the other hand, the procedure MAMMOPLASTY OR MAMMOPLASTY FOR THE 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.
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, 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 relevant to point out that, in the case of old, non-adapted plans (plans contracted until 01/01/1999 and not adjusted to Law n.º 9.656/1998, under the terms of its article 35), coverage for the procedure in question will only be due if there is a provision to that effect in the respective contractual instrument.
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