Topic: Insurance is denying BMX , need help!

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Posted on: Jan 24, 2011 03:40PM

Posted on: Jan 24, 2011 03:40PM

Elaine586 wrote:

I want a prophelactic BMX due to strong family history and a couple of abnormal mamograms. I have lost my Mom and younger Sister to BC. My other Sister is thus far, a survivor. That is my entire family. My Mom and two sisters! That is a very strong family history. Also lost my Aunt on my Fathers side.

I have letters from 5 Dr.s and a genetic councelor stating i need to have this done. I have BSBC of Mi. MSPERS (school retiree).  In my contract it states they cover the BMX in cases of strong family history. The diagnosis code is V16.3. Strong family history of breast cancer.BUT ,my customer service rep at BC informed me they don't  cover anything coded that starts with a 'V". It is the most insane frustrating circle.

Does anyone have experience with this? Any thoughts, tips or advice is welcomed and appreciated!

Planning a PBM
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Jan 24, 2011 04:06PM lago wrote:

Screw the customer service rep. This is unacceptable.

I initially had an issue with BC&BC of MA denying my PS bill for reconstruction. It took a while to get it sorted out. BC&BS of MA said the code was too general. Ironically BC&BS of IL had no problem with the code. MA wants the code for each stage of the reconstruction. It took a while to find that out. (I was the one who found out that was the issue after several calls to BC&BS).

It's possible that there is another code for that procedure that they will cover. Only the doctor's office can call and get that info. They will not give you the code.

If that's not it go above your customer service rep. Someone higher up might be able to figure this out.

Yes you need to be a pest with insurance companies. They will do anything to get out of or delay paying. The also tried to deny my $40 blood draw for the BRCA test but covered the actually BRCA testing. I finally got them to pay part of it. I know, small amount but I was paying a lot for Cobra. No need to pay any extra!

DONE!! • 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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Jan 24, 2011 05:04PM Cameron wrote:

...Oh boy am I adding this one to my "favorite topics"...

I am going to keep an eye on you, looks like we'll (hopefully) be PBMX'ers together, and the sooner the better, right?

I am currently choosing not to schedule my surgery until I get the proper codes so I know I'll be covered. The last thing I want is to be is post-op, and under the influence of pain meds, sitting on the phone, on hold for 30 minutes, holding a bill that says I owe them twenty billion dollars, and crying my head off.

So I'm not in your boat (yet) because I haven't been told "no" yet. We'll see. I'm remaining optimistic because my doctors say it should be done, and once it's done, reconstruction MUST be done. I also have Minnesota law on my side, I've researched.

If need be, I could send them a photo of my boobs and ask the insurance company "could YOU walk around like this?"  Unlike you, I have absolutely no history of breast cancer in my family. What I do have is a left breast with a giant fast growing tumor along with hundreds of fibroadenomas, and a right breast with smaller more painful tumors.

Maybe the insurance companies should consider what a favor we're trying to do for them. You, with your history, clearly are at risk. And me, with my tumors, well I have so many hiding places for cancer to hide out and stage a hostile takeover...places that can't truly been seen, even on sonogram, because of the tumors. Why don't the insurance companies understand we're NOT trying to do this for "Fun". WHO wants to get their breasts removed, just for "funsies?" I don't think so. Imagine the money we'll save them in the long run. I know that if I don't get this surgery, I'm looking at more mamos, sonos, MRIs, MBIs, Biopsies, and lab tests than they can ever understand. Add in the cost of my therapist once I go stark raving mad, and wow, it's not pretty.

Sorry about the rant...all I have to do is think about insurance and my inner snark-beotch comes out.

Where I am: I have my radiologist, and my general surgeon behind me. The paperwork has been faxed to insurance, and tomorrow a medical letter of necessity will be dictated and sent. I will stay tuned to your dilemma and wish you the best!

In the meantime, if I were you, I'd call the person you know best at your doctor's office. It will probably be a nurse or a "care coordinator". That person will be your "go-to" helper to get this surgery accomplished. Tell them you NEED someone to help you see this through. Tell them, if the doctor says it's necessary, SURELY there is another code he can place on the procedure, a code which your insurance will cover. 

Just 5 minutes ago, I got off the phone with my "go-to" girl.  I'll tell you how I knew she should be my appointed helper: I told her my insurance company said they hadn't heard anything from the doctor, and I was calling to check on things. She was shocked they told me that, because she faxed them my paperwork like 8 hours ago. BUT then, she said that it was a process, and these things take time to work their way through. She seems like I was impatiently harassing her or something. To shift her mood, I gave a meek polite little thank you, and then I apologized for bothering her, by explaining that "I was sorry for being so pushy but that my tumors have me in a lot of pain." And then I think I sounded choked up and on the verge of tears. And WOW did she sound like I was her long lost daughter in need of a mama bear's help. She started saying how she'd call to expedite, follow up, keep me informed, rest assured, hang in there, don't worry, yada yada. 

Mission accomplished.  (wink)

~ Cameron @~;~~

~ Cameron ~ "I think you were only infatuated with your TEs. True love requires squishiness" -thanks E-day buddy!
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Jan 24, 2011 05:22PM lago wrote:

BTW the American Cancer Society has social workers that can help with these issues. Have you contacted your local office?
DONE!! • 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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Jan 25, 2011 10:43AM Elaine586 wrote:

I wrote a long, thought out response yesterday. It's gone. Undecided

Thank you both for your thoughts and advice!! 

Thank you Cameron for sharing your story. I wish the the very best and hope your insurance steps up and does what you have been paying for! Who is your PS? Where are you having it done?

I reasearched all of my options, initially had a date set for BMX and implant reconstruction. I just had a bad feeling about it. Then I discovered info on DIEP/SGAP and Dr Massey. I knew that was the right answer for me.

Initially, BCBS said yes , I am covered. It is a covered procedure. I saw it in black and white. I meet the critreia required.  I requested out of network exception for NOLA St Charles.They would only pay a very minimal amount, & St Charles turned me away. 

Then Jenny and Dr Massey scheduled me at Fairway in NOLA, they are in network. All was fine, til Jenny requested pre auth. BC BS did a pre auth for the hosptial, but would give one for Dr Massey or the surgeon doing the mx.  They told Jenny she didn't need one because it was a covered procedure. But they said they don't guarentee pmt. They always have that disclaimer. Jenny wanted a pre auth to cover all of our butts. 

She couldn't get anywhere with them, so I called. They said , yes, it was covered and it was between me and my Dr as to whether it was medically neccessary. No real answers, so I requested a nurse case manager. She is trying to help. In the mean time, I got a call from my "my" customer rep  saying they were not going to cover it! The diagnosis code for the strong family history is V16.3 . She said they don't cover anything "V"! The exact same time she was on the phone with me, Jenny was getting a call from the ombudsman saying if she faxed all the letters, background, etc, they "might" reviw it! SO FRUSTRATING!!!

I hope to find someone that went through this, find out what code the surgeon used to bill it. "My" customer service rep wouldn't tell me. Yell

I will look into the ACS, thank you Lago!  Looking forward to hearing how it works out for you, Cameron!!!

Planning a PBM
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Jan 26, 2011 07:47PM carcharm wrote:

I believe the coders that prepare this for billing should look up and review the coding clinic on how to code this. I think they should be using the coder for breast cancer... try calling the medical records department and talking with the coding manager. Tell her that someone told you about a coding clinic on coding the prophylactic removal of breast for family hx of breast cancer. It may be the V code but I don't have access to an encoder since I am out of work currently.

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Feb 10, 2011 08:45AM mdg wrote:

Here is a website that lists codes.  Maybe if you call your insurance or look on line on their site it will spell out what you need to have it coded as.  Surely your doc's have dealt with this before.  Did you talk to their medical biller?   There has to be a way around this....

Maria Visit my BC Blog at breastcancerwontdefineme.blogs... Dx 12/13/2010, IDC, 1cm, Stage I, Grade 2, 0/2 nodes, ER+/PR+, HER2- Surgery 12/23/2010 Lumpectomy: Right Surgery 1/27/2011 Mastectomy: Right; Prophylactic mastectomy: Left; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Chemotherapy 3/3/2011 Cytoxan (cyclophosphamide), Taxotere (docetaxel) Hormonal Therapy 5/19/2011 Surgery 6/22/2011 Reconstruction (left); Reconstruction (right) Surgery 12/10/2011 Reconstruction (left): Nipple reconstruction; Reconstruction (right): Nipple reconstruction
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Feb 20, 2011 10:01AM Elaine586 wrote:

Thank you all so much for the advice, links and sharing . As of now, my case is being "reviewed". They said it will take about 3 weekes to get and answer. That was 2 weeks ago. Jenny at Dr. Masseys office siad she has never ran into this before with an insurance company! I am stunned. We have MSPERS BC/BS PPO. That is "supposed" to be one of the better plans. I have found them rude and unhelpful! I do have a nurse case manager that is very nice and supportive, but she can't help with the approval.

MDG, Thank YOU!!! I will forward that to Jenny... and look to see if I can figure it out. At first glance it has medical terms that are foreign to me. LOL  I need to study and reseach. I will not give up.

My Gyn suggested a lawyer if they deny me. Rarely does the work attorney come out of a Dr.'s mouth! LOL   

Planning a PBM
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Mar 7, 2011 09:46AM edwards750 wrote:

Elaine...don't have your problem specifically - maybe you have solved this because your post was in January but I am concerned about the financial end of this nightmare. We do have insurance coverage - at least through my husband's job. He has Blue Cross which I have to admit has been a big benefit to us. The doctor and hospital we are using are all part of the network so they submit their allowable charges to the doctors and hospital. Our out of pocket is manageable but this is only the beginning of the medical floodgate charges. The charge that really bugs me is the Womens Health Center where I had my mmgram, original and node biopsy charged over $5700 just for "using" their facility and it was more than the hospital where I had my lumpectomy. Really? I am not going to stress over the bills...we have a flex account as well but it is so telling why a lot of people dont go to the doctor. I agree you have to take on insurance companies yourself hopefully with the help of your doctors, and push, push, push them. I have no problem doing that. We are all going through difficult times; the last thing we need is financial worries too.

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Mar 8, 2011 12:08AM Elaine586 wrote:

Edwards 750 & JBin, it has not been resolved. At all. It is "being reveiwed". The thing is , my policy sates a PBX  IS covered under certain criteria. IE strong family history, abnormal mamograms, etc. I DO meet the criteria they have in place. The first few ppl I talked to at BCBS said it WAS covered. They wouldn't put it in writing for Jen at Dr Masseys office. So, I called to see what was needed for a pre approval. I got the run around, but I kept calling. Then suddenly I got a call say it was denied and wouldn't be covered. The code they have is for the procedure is a V code. And, according to "my" customer rep, they don't cover V codes. Its insane!

I was tested for BRCA. I came back negative. But since my Mom and Sisters were not tested, that doesn't really give me confidence.

Thank you for your insights and thoughtfulness. I do so much appreciate it.

Edwards 750, I hope your insurance will step and and do what they promised all the years they were collecting the premiums.You are right, stressing over money is the LAST thing you need to do. You have more important things to spend good energy on!  Thank you so much for sharing. I wish you well.


Planning a PBM
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Mar 8, 2011 01:23AM - edited Mar 8, 2011 02:19AM by AnnNYC

JBinOK, while it is true that the majority of women who develop BC do not have a strong family history, the converse is not true.  The fact that only about 15% of women who develop BC have a strong family history does not translate to "only 15% of women with a strong family history will develop BC."

For example, the average American woman has about a 12% chance of developing breast cancer. [see]

But women who are BRCA1 or 2 positive have a 65-80% chance of developing BC

While Elaine is not BRCA-positive, she is likely in the category of "50% of families with hereditary breast cancers" who don't have the BRCA mutation, in which case her risk is higher than the 12% average. This website says that having 2 first-degree relatives with BC increases a woman's risk by 3-fold (which would make the risk 36%) -- and Elaine has 3 first-degree relatives.  And even from a completely mercenary standpoint on the part of the insurance company, a prophylactic bilateral mastectomy and reconstruction in a healthy woman is almost certainly going to be less expensive than treating breast cancer...

Elaine, I hope the insurance review comes through for you, and I'm so sorry you're having to wait like this.

Hugs, and fingers crossed,


Dx 3/9/2007, IDC, <1cm, Stage I, Grade 2, 0/5 nodes, ER+/PR+, HER2-

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