2011 ORS § 743A.110¹
Mastectomy-related services
  • expedited external review required

(1) As used in this section, mastectomy means the surgical removal of all or part of a breast or a breast tumor suspected to be malignant.

(2) All insurers offering a health benefit plan as defined in ORS 743.730 (Definitions for ORS 743.730 to 743.773) shall provide payment, coverage or reimbursement for mastectomy and for the following services related to a mastectomy as determined by the attending physician and enrollee to be part of the enrollees course or plan of treatment:

(a) All stages of reconstruction of the breast on which a mastectomy was performed, including but not limited to nipple reconstruction, skin grafts and stippling of the nipple and areola;

(b) Surgery and reconstruction of the other breast to produce a symmetrical appearance;

(c) Prostheses;

(d) Treatment of physical complications of the mastectomy, including lymphedemas; and

(e) Inpatient care related to the mastectomy and post-mastectomy services.

(3) An insurer providing coverage under subsection (2) of this section shall provide written notice describing the coverage to the enrollee at the time of enrollment in the health benefit plan and annually thereafter.

(4) A health benefit plan must provide a single determination of prior authorization for all services related to a mastectomy covered under subsection (2) of this section that are part of the enrollees course or plan of treatment.

(5) When an enrollee requests an external review of an adverse benefit determination as defined in ORS 743.801 (Definitions) by the insurer regarding services described in subsection (2) of this section, the insurer or the Director of the Department of Consumer and Business Services must expedite the enrollees case pursuant to ORS 743.857 (External review) (5).

(6) The coverage required under subsection (2) of this section is subject to the same terms and conditions in the plan that apply to other benefits under the plan.

(7) This section is exempt from ORS 743A.001 (Automatic repeal of certain statutes on individual and group health insurance). [Formerly 743.691; 2011 c.208 §1; 2011 c.500 §41]