DMX and Medicare Coverage
I have left side IDC and am getting ready to schedule surgery. My right side has scanned clear. I’m considering a DMX and going flat, for symmetry and so I don’t have to worry about future screenings and risks on the right side. A nurse navigator just told me that Medicare won’t pay for the double! In the two months I have been getting all these tests and appointments, no one has ever said this before. I question whether it’s true, as it seems like appropriate risk mitigation and Medicare would pay for a reconstruction. Has anyone had any experience with this issue?
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The WHCRA which applies to private insurance does not apply to Medicare which requires prior authorization for that situation. If you don't have a medical reason for recurrence risk mitigation (like a BRACA gene or >20% risk of recurrence) see if the surgeon can file for preauthorization claiming medical necessity for orthopedic reasons.
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Medicare covers mastectomies and breast reconstruction, there are procedure codes for those. I came across a couple of internet articles stating that there isn’t a blanket rule denying coverage for prophylactic mastectomy, but medical necessity must be documented, which can include BRCA gene mutations or family history and personal history of BC. I’m trying to find relevant regulations or other guidance, but still looking. I have multcentric IDC, three sites, and 3 cousins and a great aunt with BC. If anyone has successfully made a case with Original Medicare, I would like to hear that. I have a supplement plan but it only kicks in for things Medicare covers.
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Hello Time28,
I am sorry for the obstacles that this seems to cause in your Journey for Health and Healing and making the best decisions for yourself. As if this Journey is not hard enough for all of us…..
I literally just had the same procedure - a DMX with the reverse situation. My right side had IDC and my left was clear; however, I have a strong family history of BC and decided to go flat for symmetry and the best chances of moving on from this horrible disease. I work in a healthcare facility, and my husband is a doctor as well. He said that if you can provide the medical necessity from your doctor or surgeon (such as strong possibility of recurrence or family hx etc.) in writing and contact Medicare yourself by phone, you should be able to get it covered. The written documentation and the prior approval by Medicare are key. Hope this can work for you, and that you get the coverage you deserve for the best treatment possible for your optimal Health. Persist and may the way open to make it work out for you!
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