Topic: Insurance says no to out of state surgeons

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Posted on: Dec 22, 2010 11:55AM

Posted on: Dec 22, 2010 11:55AM

AndiBaby wrote:

Can anyone offer some advice? A friend's mom has been diagnosed with breast cancer. She lives in Connecticut. She met with different surgical teams and has decided to go with Drs. Ashikari and Salzberg in Westchester NY b/c they will do nipple-sparing and importantly, the immediate insertion of implants during the mastectomy with no anticipated additional surgeries. It's important b/c she is a stroke risk and on coumadin, so the less procedures she has to deal with the better. She has Medicare and supplemental insurance policy; they are telling her they won't approve her going out of state. They are telling her there are other surgeons in CT who do mastectomy this way, which is actually not accurate (now she has to call all of them to verify that it's not accurate and/or they don't have much experience with it). My friend is battling the insurance company and I advised her to contact the CT insurance commissioner as well. Any other advice, resources, experiences? Her surgery was supposed to be today, now pushed back to January, and she has cancer...!!! Thanks so much for any help.

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Dec 22, 2010 02:21PM lago wrote:

I can't really offer much help but I do hear from my parents that Medicare is so screwed up. Half the time the do get it wrong.

DONE!! goo.gl/IoaN6U • Tattoos 2.7.2012 • Nipples 10.6.2011 • Exchange 6.24.2011 • Chemo 1.18. 2011 • BMX 8.31.2010 Dx 7/13/2010, IDC, 5cm, Stage IIB, Grade 3, 0/14 nodes, ER+/PR+, HER2-
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Dec 22, 2010 02:51PM lauri wrote:

This probably won't be popular, but ...has she considered NOT doing reconstruction ?  Simpler surgery, fewer side effects.  I was 62 when diagnosed, and my feeling was that people don't really SEE older women, so why bother ?  Getting rid of the cancer and moving on to the rest of the treatment was what I wanted to do.  If she would like to hear about non-reconstruction, there's a whole topic or she could PM me.

Sounds like the in-state-only problem is not with Medicare but with the supplemental insurance carrier -- and without knowing the provisions and restrictions of her policy, we can't say.  But the state insurance commissioner is a good place to start.

From the ashes of disaster grow the roses of success Dx 3/8/2006, ILC, Left, 6cm+, Stage IIIB, metastasized to bone, Grade 2, 11/12 nodes, ER+/PR+, HER2- Dx 11/15/2021, ILC, Stage IV, metastasized to bone Hormonal Therapy 11/27/2021 Femara (letrozole) Targeted Therapy 12/2/2021 Ibrance (palbociclib) Radiation Therapy Whole breast: Breast Surgery Mastectomy: Left Chemotherapy AC + T (Taxol) Hormonal Therapy Arimidex (anastrozole)
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Dec 31, 2010 08:56PM - edited Dec 31, 2010 08:57PM by Fearless_One

One step with nip sparing  is a common procedure.   I find it odd that she says no surgeon in the state of CT can do it.   I have private insurance and it wouldn't cover an out of state surgeon - this is not only a medicare issue.  

Recon with no insurance costs about 20K.   So she has 3 options.

A CT surgeon

Pay out of pocket 20K

Have no recon.

lump/chemo/rads/hyster-ooph/mastectomy/implants
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Jan 2, 2011 09:42AM MaryNY wrote:

AndiBaby: I live in Westchester but went with a surgeon in CT. However in my case I had a lumpectomy although I was originally scheduled for a mastectomy with a Westchester-based surgeon. I went for two second opinions, one with a BS at Sloan-Kettering and the second was the the BS in CT who finally did the surgery. I was very happy with my final decision.

My insurance now will no longer cover going to see doctors out of state, so my situation is like the reverse of your friend's mom.

Mary ~~ lumpectomy 8/10/2009, Oncotype DX 18, Chemo 10/28/09--2/1/10 AC*4, CMF*4 Dx 5/19/2009, IDC, 1cm, Stage IIA, Grade 2, 2/6 nodes, ER+/PR+, HER2-
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Jan 2, 2011 08:04PM AndiBaby wrote:

Thanks so much for all of your responses. So I'm pretty sure it will work out b/c now that it's year end, she can switch insurance to a PPO option and get covered for the surgical team she really wants. Her surgery has been delayed but I think it will be this week. Tough stuff, but I think it will be OK for her. thanks again!

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Jan 19, 2011 07:54AM glanter wrote:

Standard Medicare does not have a process for pre-certification or pre-authorization so the "no to out of state" has to be coming from elsewhere. 

Gail

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