What to Say, What to Submit, and How to Appeal

If you are filing for reimbursement for nipple areola micropigmentation after mastectomy and breast reconstruction, this blog is for you. Whether you are a breast cancer survivor or a previvor who underwent prophylactic mastectomy due to family history or genetic mutation, the final stage of reconstruction matters.

And yes — it is legally protected.

Under the Women’s Health and Cancer Rights Act (WHCRA) of 1998, insurance plans that cover mastectomy are required to cover all stages of breast reconstruction, including procedures to restore symmetry and appearance.

Nipple areola micropigmentation is not cosmetic. It is reconstructive.

This guide will walk you through:

What to say when calling insurance before your appointment
What documentation you will need
How reimbursement works
What to do if your claim is denied
How to file an appeal

Why We Collect Payment Upfront

We have attempted to contract with insurance carriers. However, most insurance companies will only credential physicians for reconstructive billing. Because we are registered nurses — not physicians — we are considered out-of-network.

That means we must collect payment upfront.

However, we provide all necessary documentation to help you file for reimbursement, and we guide you step-by-step through the process.

Step 1: Call Your Insurance BEFORE Your Appointment

Call the Member Services number on the back of your card. Here is a script you can use:

Script: How to Talk to Insurance Before Your Tattoo

“Hi, I am a breast cancer survivor/previvor. I have had a mastectomy with breast reconstruction, and I am about to complete the final step in my reconstruction called nipple areola micropigmentation.

The provider is called Perky. They are an out-of-network provider, and I will be filing for reimbursement after the service is completed.

Given the highly specialized and sensitive nature of this procedure, I would like to know if this can be applied to my in-network benefits.”

Pause and let them respond.

If needed, add:

“My plastic surgeon does not offer this service in-office.”
“I was referred to this provider by my plastic surgeon.”
“There are no oncology-specialized providers in my area.”

If they say it cannot be applied to in-network benefits, ask:

“Is there someone in-network who performs nipple areola micropigmentation in a clinical setting?”
“Can a Network GAP exception be requested given the specialized nature of this service?”

If they say it can be applied to in-network benefits, ask:

“Is a prior authorization required?”

“Is there anything needed before the procedure to ensure reimbursement?”
“Would a referral from my PCP or surgeon be required?”

If they state it is cosmetic, you may say:

“Under the Women’s Health and Cancer Rights Act (WHCRA), federal law requires coverage for all stages of reconstruction following mastectomy, including procedures to restore appearance and symmetry. Can I speak with a supervisor or initiate a waiver review?”

Always ask for:

The representative’s name
A reference number for the call

Document everything.

Step 2: What You Will Need to File for Reimbursement

After your procedure, you will receive:

An itemized receipt with ICD-10 diagnosis codes and CPT procedure codes
A letter of medical necessity
A completed reimbursement form
(Optional but helpful) A recent progress note from your surgeon clearing you for tattooing or referring you

Submit these documents through your insurance portal or via their claims mailing address. (typically located on the back of your insurance card)

Processing typically takes 30–90 days.

Step 3: If Your Claim Is Denied

If you receive a denial: Do not panic.

Read the Explanation of Benefits (EOB) carefully. Common denial reasons include:

Out-of-network provider
Cosmetic procedure
Lack of prior authorization

Denial does not mean the end of the process.

It means you move to appeal.

Step 4: Filing an Appeal

You have the right to file an internal appeal.

Your appeal should include:

A formal appeal letter
Your EOB
Letter of medical necessity
Surgeon referral (if available)
Any documentation regarding lack of adequate in-network options

Many insurance companies also allow verbal testimony during appeal review.

If your internal appeal is denied, you have the right to request an external review under the Affordable Care Act. The U.S. Department of Labor or the U.S. Department of Health and Human Services (HHS) oversees the external review process for most plans in Texas. https://tdi.texas.gov/consumer/complaint-health.html

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 said on the matter:

“In my case, it’s not about the money, but about the principle. I plan to exhaust all my options in fighting this claim denial.”

She won.

You Should Not Have to Fight This Alone

This is the final stage of reconstruction.

It is not cosmetic.
It is not optional.
It is federally protected.

If you have questions about reimbursement or appeals, please fill out the form below and our team will guide you in the right direction.

Insurance Reimbursement for Nipple Tattooing: