Insurance denial
Hi everyone,
I am a 2 time survivor In 2003 I had a lumpectomy, radiation, chemo and aromatase inhibitor for 10 years. Recurrence in 2012 in same left breast and opted for masc with reconstruction ( I had lost my husband a month later so wasn’t thinking too clearly) Anyways now finally looking for symmetry. Having a reduction, lift and Lipo on right breast. My insurance Cigna is denying the Lipo I know of the Women health and cancer right act would protect me with this denial.
I will file an appeal but was hoping to see if anyone has experience with this.
thank you so much and good health to all!
Joann
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I had to pay for the liposuction that was done during the revision (fat grafting) part of my DIEP reconstruction. The plastic surgeon said that it was optional because insurance did not cover it. It was about $2,000.
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Hey there, @joannweb! We wanted to share two articles from our website that might provide some insight into reconstruction and navigating health insurance challenges. Here are the links: Managing Your Health Insurance and Breast Reconstruction Surgery and Health Insurance. We hope you find them helpful, and please feel free to reach out if you have any questions or need further support.
Wishing you all the best!
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Hi @joannweb , Unfortunately some insurance companies consider fat grafting “experimental / investigational” while others will pay for it. It is possible to appeal that reason by showing the procedure is "medically necessary" for function rather than cosmetics citing medical publications and your health record. Contact your plastic surgeon's office to see if they have ever been able to successfully appeal that type of ruling and if they think it could be done in your case.
I have filed six successful appeals with one of the denials "experimental/investigational" but not for reconstruction. That one was for trigeminal neuralgia laser surgery since my medical condition precluded the SOC surgery. My burn surgeon had successfully appealed this type of denial before and published a case study about my success so it could be used as ammunition by future patients.
The first step would be to get a copy of the current medical utilization criteria for breast reconstruction from Cigna since that gives you the detailed information you need to base the appeal on. Filing a successful appeal can be a long process; internet search skills and enough of a scientific background to understand medical papers helps. A few of my appeals have been slam-dunks (post procedure denial of Oncotype and bc tumor surgical pathology) while others took up to a year. All the best!
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Thank you all for your very useful information! I have Cigna which I think isn’t great to begin with.
i can pay out of pocket $2000 for the liposuction on my right side. Not sure how I can spin it to be medically necessary.
@pwregrinelady were you happy with your decision of the Lipo?
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Yes, I am happy with the result, but I will say that it was very painful as my whole lower back was bruised and it was done outpatient so there was no aftercare. My plastic surgeon made it sound like the reconstruction would not be complete without the fat grafting. I think they look more rounded with the liposuction and more natural looking. Good luck!
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I am glad I found this thread. My plan is for right single mastectomy with immediate DIEP reconstruction along with lift/ fat grafting on opposite side for symmetry. I’ll check with insurance before finalizing my plan.
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Do keep in mind that the best way for these companies to profit is by denying claims! Be sure to appeal as Maggie describes above. I was successful 4/4 times. A phone conference resulted in reimbursement for my wig which was actually a “cranial prosthesis”. Two others were in person at an office with their lawyer, a doctor plus someone else who called us.
Both were probably designed as intimidating scenarios however I knew what my benefits were. They had to allow follow-up MRIs due to my diagnosis. They agreed but then dragged their feet on sending me an approval letter, delaying my scan by an extra month. Another situation involved coverage of a lymphedema machine for which I had prior authorization.
Since my attempts to demonstrate that to them fell flat, I filled out a simple form that our state insurance commissioner provides on line. That judgment resulted in fines plus interest. Finally, because I had a genetic panel billed as only a BRCA test, for which I met eligibility requirements, they tried to evade their responsibility for that. Don’t give up. You CAN win.
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Hey Joann, first—just want to say you're incredibly strong for everything you've been through. And you're absolutely right to push back on the denial.
Yes, under the Women’s Health and Cancer Rights Act (WHCRA), your insurance is required to cover procedures needed to achieve symmetry after a mastectomy—including reduction, lift, and yes, lipo if it’s part of the reconstruction process. Cigna should know this, but denials like this still happen more often than they should.
Here’s what I’d suggest for your appeal:
- Reference WHCRA directly in your letter. State that the lipo is being done to achieve symmetry following mastectomy reconstruction, and is covered under federal law.
- Ask your surgeon to write a letter of medical necessity. It should clearly state that the lipo is part of the reconstructive process—not cosmetic—and is required to match the reconstructed breast.
- If you're unsure how to structure the appeal, check out Counterforce Health—it's a free tool that helps write appeal letters based on your denial reason. I’ve used it and it takes a lot of the guesswork out.
You’re definitely not alone in this, and you’ve got a strong case. Wishing you a smooth appeal—and good healing ahead.
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Joann has not signed in to bco in just about a year. Hope she is doing well.
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Given recent changes in regulation and the administration, I am hearing many more women are being denied reconstruction and revision care by all companies, but especially United Healthcare. I know my revision has been denied four times, and we now have to go to mediation (sure, that'll go well…). For the most recent "special review," my surgeon submitted 120 pages of documentation—and the appeal was denied less than 24 hours later, so clearly no one reviewed anything.
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Hi @jmchambers, and thanks for posting!
You might find some helpful information on this page from our site:
We hope this helps!
—The Mods
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Hi @jmchambers, It’s unlikely anyone read the 120 pages because computers and AI are used so much by insurance companies. I had a denial and rescinding of the payment to a hospital happen two years after I had won the appeal. I was told the computer had done it automatically and it would be corrected. It took several months for that to happen.
If you are going to mediation (or filing any appeal) it helps to summarize your argument in sentence statements and then reference your medical record, scientific study or article as support for your position. If you number the medical record pages you can just refer to p.93 and highlight, underline or star the relevant entry. You can refer to a scientific study or article by having a numbered bibliography (like an English paper) and noting the article number and the page in the paper that is relevant. It’s kind of like a geometry proof where you have the statement in one column and the reason in the other. This keeps the negotiations focused on the facts of your case so it doesn’t devolve into generalities of what they cover. It takes time to do this but I remind myself that my time is worth the $35,000 or whatever the hospital billed for my treatment.
Check to see what your state insurance commission rules are so you can let the insurer know where you’ll go next. Some states are better than others and not all plans fall under its purview. I was in an uncovered group but once a patient advocate at the hospital called someone who actually makes decisions in the insurance company and threatened to report my case. It was paid immediately without a further appeal, probably because they figured dealing with the state commissioner would cost them too much time and money.
Good luck with mediation.
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