Coverage for Nipple Tattooing:
Your Insurance Reimbursement & Appeal Guide
You Shouldn’t Have to Fight for the Final Step of Reconstruction.
Nothing about mastectomy or breast reconstruction is cosmetic.
And nipple restoration — also known as 3D areola tattooing — is not an “extra.” It is a federally protected part of reconstruction under the Women’s Health and Cancer Rights Act (WHCRA).
Yet many women are told, “That isn’t covered; it’s considered cosmetic.”
If your claim was denied, you are not wrong to question it.
You deserve safe, skilled care. You deserve a result you feel good about. And you deserve to understand your rights.
This page will walk you through exactly how to request reimbursement, file an appeal, and advocate for yourself with clarity and confidence.
This document is read-only. Please copy and paste the full template into a new document and replace the italicized sections with your personal information before submitting it to your insurance provider.
The Law: What Insurance Is Required to Cover
Under the Women's Health and Cancer Rights Act (WHCRA) of 1998, insurance plans that cover mastectomy must also cover:
All stages of reconstruction
Surgery and reconstruction of the other breast for symmetry
Prostheses
Treatment of physical complications
Micropigmentation (areolar tattooing) as part of breast reconstruction
Nipple-areolar tattooing is federally recognized as part of breast reconstruction.
It is not cosmetic.
So Why Are Claims Sometimes Denied?
We actively attempted to establish contracts with major insurance carriers so that our services could be processed in-network. However, most insurance companies will only credential physicians for this type of reconstructive billing. Because we are registered nurses — not physicians — they declined to contract with us.
This is not a reflection of the medical necessity of the service. It is a structural limitation within insurance credentialing systems.
As a result:
We are considered out-of-network.
Payment must be collected upfront.
We provide detailed receipts and documentation so you can submit for reimbursement.
Here’s the reality though — as much as we arm you with everything you need for insurance reimbursement, we unfortunately cannot guarantee that you will be reimbursed after the service.
Although insurance is required by law to cover this service, there are loopholes around that. How much they reimburse, if at all, depends on factors like your individual contract with them, the allowable amount for the service, if they’ll apply the service to your in-network benefits, and how much of your deductible you have met.
Many insurance plans will state that “in-network providers are available.” However, those providers may not offer:
A sterile, clinical setting
Experience working with radiated or scar-compromised tissue
Oncology-specific expertise
The aesthetic precision required for permanent restorative tattooing
Results aligned with your personal goals
These tattoos are permanent (or they should be). Women deserve the right to choose:
Who performs their restorative tattoo
Where it is performed
The level of clinical oversight
The aesthetic outcome that feels right to them
You should not be financially penalized for prioritizing safety, experience, and a result you will live with for years to come.
How We Walk You Through the Insurance Reimbursement Process
Insurance reimbursement can feel overwhelming — especially after everything you’ve already navigated through diagnosis, surgery, and reconstruction. We believe you deserve clarity and support during this final step.
While we cannot guarantee coverage, we walk each client through the reimbursement process step-by-step and provide detailed documentation to support your claim.
Here is how we recommend approaching it:
Step 1: Contact Your Insurance Provider Before Your Appointment
Call the Member Services number on the back of your insurance card.
Let them know:
You have undergone mastectomy and breast reconstruction
Your reconstruction was covered due to breast cancer and/or a genetic mutation or strong family history
You are seeking the final stage of reconstruction: nipple areola micropigmentation at Perky
Ask the following:
Is nipple areola micropigmentation a covered benefit under my plan?
Is anything required prior to having this service completed?
If Perky is considered out-of-network, are there any exceptions available?
Can a Network Gap Exception or GAP extension be requested due to the specialized and sensitive nature of this service?
You may qualify for an exception if:
In-network providers are medically inadequate for your case
You require a clinical setting due to radiation or scar complexity
There are no oncology-specialized providers within network
A Network Gap Exception can allow out-of-network services to be processed at in-network rates.
Very important:
Always ask for the name of the representative and a reference number for the call. While calls are typically recorded, having documentation of who you spoke to and when can be invaluable if you need to reference the conversation later.
Step 2: Submit Your Initial Claim
After your procedure at Perky, you will receive:
An itemized receipt with diagnosis and CPT codes
A completed reimbursement form
A letter of medical necessity outlining why this is reconstructive, not cosmetic
Many of our clients are referred to us by providers who do not offer this service and we always include that in our letter
Submit these documents through your insurance portal and allow time for processing. Most plans take 30–90 days to issue a determination.
If Your Claim is Denied:
Review Your Explanation of Benefits (EOB)
Carefully review the stated reason for denial.
Common reasons include:
“Out-of-network provider”
“Cosmetic procedure”
These reasons do not necessarily mean you are not entitled to coverage.
File an Internal Appeal
If denied, submit a formal internal appeal. Include:
Your appeal letter (click here to download our template)
This document is read-only. Please copy and paste the full template into a new document and replace the italicized sections with your personal information before submitting it to your insurance provider.
Your Explanation of Benefits (EOB)
Supporting documentation (such as a referral or letter from your surgeon)
Letter of medical necessity (if available)
Many insurance plans offer an option to provide verbal testimony as part of the appeal review process. If available, we encourage you to participate.
Request an External Review (If Necessary)
If your internal appeal is denied, you have the right to an external review under the Affordable Care Act.
In Texas, this may be done through the Texas Department of Insurance.
Federal plans may be reviewed through the U.S. Department of Labor or the Department of Health and Human Services (HHS).
External reviews require insurers to have an independent third party evaluate your case.
A Real Client Story: She Appealed — And Won
One of our clients with stage 4 breast cancer was denied coverage by Blue Cross Blue Shield Federal Employee Plan.
The denial reason?
“We have in-network providers available.”
Her response?
A Network Gap Exception appeal.
She argued:
Surgical continuity of care
Inadequacy of in-network providers for her complexity
Specialized expertise required for radiated/scarred tissue
Financial burden after meeting out-of-pocket maximums
She won.
You Deserve Support Through This Process.
Insurance language can feel clinical and intimidating — but this is personal.
This is your body.
Your reconstruction.
Your final step.
If you have questions about reimbursement, documentation, coding, or the appeal process, we are here to help guide you in the right direction.
Please use the form below to submit your questions, and a member of our team will respond as soon as possible. While we cannot speak directly to your insurance carrier on your behalf, we can help you understand your options and ensure you have the appropriate documentation to advocate for coverage.
You do not have to navigate this alone.
