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Topic: Upset, insurance won't cover reduction after lumpectomy

Forum: Breast Reconstruction — Is it right for you? Discuss timing and various procedures and techniques.

Posted on: Nov 28, 2013 07:24AM, edited Nov 28, 2013 07:26AM by Jstlucy

Jstlucy wrote:

Hello everyone,

This is my first post and I'm hoping someone can shed a light on the issue of insurance coverage for asymmetry after lumpectomy and rads. I was set for breast reduction surgery on my unaffected breast when my insurance company BCBSAL denied coverage saying they only cover reconstruction after mastectomy . I'm in tears , my effected breast has drawn up to almost half the size of my other dd breast. My surgeon assured me it would be covered because it it due to BC . What do I do ??? Anyone out there had this happen?

Mucinous IDC 2cm 33rads

Lucy

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Posts 1 - 9 (9 total)

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Nov 28, 2013 07:41AM yorkiemom wrote:

Lucy, I'm sorry you are going through this! I have BCBSKS and they covered my lift and reduction, on the non-cancer side, after lumpectomy. I could even have another surgery to tweak things, but I probably won't do that. There is a federal law mandating insurance companies pay for reconstruction after breast cancer. I don't know specifics about lumpectomies versus mastectomies, but as I said, mine was covered. You may need to have the doctor take pictures of your lumpectomy and other side, in order to make the case. Good luck!

Life is what happens while we're making other plans.

Dx 10/18/2011, IDC, 1cm, Stage IIa, Grade 1, 2/21 nodes, ER+/PR+, HER2-
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Nov 28, 2013 07:41AM georgie1112 wrote:

Do ask your breast surgeon to write a letter and then you can file an appeal with your insurance company. Insurance companies make $ when they reject procedures. There are several appeals possible. Don't give up! My oncotype dx test was rejected but the company appealed on my behalf. It was accepted on the third appeal.

From what Ive read your BS is correct and your surgery should be covered.

Georgie

Georgie

Dx 9/2006, DCISDx 9/2006, ILC, 1cm, Stage I, Grade 2, 0/3 nodes, ER+/PR+Dx 5/2013, LCISHormonal Therapy TamoxifenRadiation Therapy ExternalSurgery Prophylactic Ovary Removal (Both)Surgery 09/26/2006 Lumpectomy (Right); Lymph Node Removal: Sentinel Lymph Node Dissection (Right)Surgery 05/02/2013 Lumpectomy (Right)Surgery 10/15/2013 Mastectomy (Both)
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Nov 28, 2013 08:26AM jenjenl wrote:

Your surgoens office can fight that fight.

34 year old wife and mother of 2 children, ages 6 and 4. BRCA1+

Dx 10/30/2012, IDC, <1cm, Stage II, Grade 2, 1/15 nodes, ER-/PR-, HER2-Surgery 11/12/2012 Mastectomy (Right); Lymph Node Removal: Axillary Lymph Node Dissection (Right)Chemotherapy 12/18/2012 Adriamycin, Cytoxan, TaxotereSurgery 04/22/2013 Prophylactic Ovary Removal (Both)Radiation Therapy 04/29/2013 ExternalSurgery 07/22/2013 Mastectomy (Left)Surgery 01/20/2014 Reconstruction: DIEP flap (Both)
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Nov 28, 2013 06:02PM lane4 wrote:

Hi, Jstlcy, please don't accept the insurance company's denial. You are entitled to have your symmetry surgery covered by law. Perhaps the plastic surgeon's office didn't submit the correct codes. The surgeon needs to indicate that your asymmetry is due to breast cancer treatment. He or she may also need to submit more information or photos. Please stay behind your doctor because you have the law on your side. If your current plastic surgeon won't appeal the denial, you can do your own appeal or go see another surgeon. Don't give up. ((Hugs))

Dx 8/10/2009, DCIS, Stage 0, Grade 2, ER+/PR+Radiation Therapy 10/26/2009 External
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Nov 30, 2013 04:02AM Martessa2553 wrote:

When I met with the PS for the first time, they had me watch a video first. The video stated there is a Federal Law instructing medical insurance companies that reconstruction must be done. As long as the doctor states "medical necessity" there should not be a problem. Asymmetry is a factor. I know a friend of mine had a lumpectomy and later her breast was filled with her own tissue/body fat.

Don't give up! I know it is stressing and exhausting...we are all together on this!

Dx 7/19/2013, IDC, 1cm, Stage I, Grade 1, 0/6 nodes, ER+/PR-Surgery 09/23/2013 Mastectomy (Right); Reconstruction: Tissue expander placement (Right)Hormonal Therapy 12/01/2013 Arimidex
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Nov 30, 2013 12:16PM aviva5675 wrote:

i have bcbsil and they covered it for me. Lx on right, reduction on non bc left. Fight it

Run Towards Not From --we can all do it...on FB and http://www.runtowardsnotfrom.com

Dx 7/2013, DCIS, Stage 0, Grade 3, ER+/PR+, HER2+Dx 8/16/2013, ILC, 2cm, Stage IIa, Grade 2, 0/8 nodes, ER+/PR+, HER2-Surgery 08/13/2013 Lumpectomy (Right); Reconstruction (Left)Surgery 08/23/2013 Mastectomy (Both); Lymph Node Removal (Both); Reconstruction: Tissue expander placement (Both)Hormonal Therapy 09/18/2013 ArimidexSurgery 01/10/2014 Reconstruction: Breast implants (permanent) (Both)
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Nov 30, 2013 12:31PM, edited Nov 30, 2013 02:07PM by SpecialK

There is no federal protection under the 1998 Women's Health and Cancer Rights Act for lumpectomy and reconstruction.  The law was written regarding mastectomy only.  Some states have enacted state legislation specifically geared to reconstruction after lumpectomy, and that is what may be offering protection to those who have had their subsequent procedures covered by insurance.  I would suggest a peer to peer review between BCBS and your surgeon and/or radiologist, after your physician has submitted photos and a letter clearly stating that a defect exists due to medical procedures for treatment of breast cancer.

Dx 9/27/2010, DCIS, Grade 3Dx 9/27/2010, IDC, 2cm, Stage IIb, Grade 3, 2/14 nodes, ER+/PR+, HER2+Surgery 11/01/2010 Mastectomy (Both); Reconstruction: Tissue expander placement (Both)Surgery 12/06/2010 Lymph Node Removal: Axillary Lymph Node Dissection (Right)Surgery 12/21/2010 Reconstruction (Left)Surgery 01/07/2011 Reconstruction (Left)Surgery 01/21/2011 Reconstruction (Left)Chemotherapy 02/17/2011 carboplatin, TaxotereTargeted Therapy 02/17/2011 HerceptinSurgery 07/20/2011 Reconstruction: Tissue expander placement (Left)Hormonal Therapy 08/01/2011 FemaraSurgery 02/24/2012 Reconstruction: Breast implants (permanent) (Both)Hormonal Therapy 06/20/2012 ArimidexSurgery 12/14/2012 Reconstruction (Both)Hormonal Therapy 07/18/2013 FemaraSurgery 03/07/2014 Reconstruction (Both)Surgery 04/02/2014 Reconstruction: Breast implants (permanent) (Left)
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Dec 3, 2013 08:38AM Jstlucy wrote:

Thank you all for your comments. I went by and picked up all the info from the PS office. They stated it was due to the lumpectomy for breast cancer . The letter from the insurance states they only cover for mastectomy . I will have to find out what Missouri law is. My BS office said he would write a letter when he gets back in office on the 9 th. I just can't believe they would leave me disfigured. I will be contacting BCBSAL myself . From everything I have been able to read online the federal law is only for mastectomy . I will let you all know the final decision . Thanks for the support

Lucy

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Dec 6, 2013 06:45AM gabriela1966 wrote:

Hello

My name is Gabriela and I live in chile . I had breast cancer in 2002 and I lost part of my left breast after the surgery - I´m know trying to get my breast rubuilt with the technique of lipotranference ( using the fat from others areas of the body and inyecting it on the breast) - no medical insurance will cover the procedure and they told me that is condider a plastic - cosmetic surgery I couldn´t believe my ears - I´m now going to make a formal complaint to the health goverment - It would a great help if anyone can inform me whether this procedure is covered by heath insurance in most countries - and if is treated it as plastic - cosmetic surgery - I apreciatte any help- thank you