Topic: HELP - BCBS Denying a part of my revision

Forum: Employment, Insurance, and Other Financial Issues — Employment, insurance, and financial concerns are common. Meet others here to discuss and for support.

Posted on: May 31, 2011 03:31PM

Posted on: May 31, 2011 03:31PM

NSWTD wrote:

I had a unimast in March 2010 with immediate recon with SIEA flap.  I had a revision in Oct 2010.  The revision required some micro fat grafting, and we used my fat from my hips that was taken using liposuction.  BCBS is denying only the portion of the surgery saying the lipo was not necessary.  How the %^&& can the doc do micro fat grafting with my body fat without doing lipo?  I just got a determination in the mail tonight saying their original decision is upheld.....the lipo is not covered.   This has ruined my night. Now I have a horrible sinking feeling in the pit of my stomach.   The micro fat grafting was done to create symetry between my real breast and the foob.   It should totally be covered as part of my recon process.   My plan says it is.  

Has anyone had this problem and if so, what tactics did it require to get this paid?    

Thanks in advance !

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May 31, 2011 03:50PM Kate33 wrote:

NSWTD- So sorry you are going through all this.  As if having BC isn't bad enough without having to deal with the financial nightmares that sometimes come with it.  First of all, was the fat grafting done by your BS or your PS.  Just curious because this is usually something the PS's do.  BS's usually just do the MX itself.  Also, is it your doctor's billing office that is saying it isn't covered or is it your insurance company?  I just had a revision as well where they did fat grafting and it was covered 100%.  I do know that a lot of times when things aren't covered it is because the doctor's office is not using the proper billing codes.  The problem is almost all PS's do boob jobs and lipo suction but they also do breast reconstruction and fat grafting.  These need to be coded and billed differently because one is elective and the other is not.  I believe my PS billed the actual fat grafting as "breast reconstruction using different method" or something like that.  The first step would be to find out how the doctor billed the procedure and the second would be to call your insurance company and talk to a supervisor about this.  It is a federal law that insurance companies have to cover breast reconstruction even if it is a revision.  Don't give up, yet.  Right before my revision my PS's billing office was telling me that my replacement implants were not going to be covered and they wanted an additional $1500.  It took 50 phone calls but I finally discovered that they weren't submitting the claim correctly.  Two days before my surgery I found out it was, in fact, covered.  Good luck and sorry you are having to deal with all this. 

Kate33 "Yes, they're fake. (@)(@) The real ones tried to kill me." Dx 12/27/2009, DCIS, 4cm, Stage 0, Grade 3, 0/4 nodes
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May 31, 2011 03:53PM NSWTD wrote:

Yes, it was done by my PS and I hear what you are saying about many procedures being elective.  I will be on the phone tomorrow morning, again !  Ugh

Thank you ! 

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May 31, 2011 04:11PM Fearless_One wrote:

I agree with Kate, could be a billing code issue.   Legally, I am pretty sure revisions for mastectomy need to covered. 

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May 31, 2011 04:30PM Kate33 wrote:

NSWTD- I just called my PS's office to see what billing codes they used for my surgery.  She said it hasn't been processed, yet, so she didn't have access to the information.  She said I should be able to find out by the end of the week.  (They're behind because of the holiday weekend.)  If I find out I will let you know because all the diagnosis and procedure codes are universal amongst doctors.  If mine went through then yours should, too, I would think.  I wish they had two types of PS's- those that do elective only and those that do recon only because this happens all the time.

Kate33 "Yes, they're fake. (@)(@) The real ones tried to kill me." Dx 12/27/2009, DCIS, 4cm, Stage 0, Grade 3, 0/4 nodes
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May 31, 2011 06:12PM NSWTD wrote:

Kate33 -

Thank you Thank you Thank you.  If you can get those codes, that will help.  I agree this has to be a glitch in the paperwork somewhere.   If they covered all the rest of the revision surgery, I am mystified as to why not this one item.  It must be the codes.   

I will check back if you post here, or PM me and I will check that.   

Thanks again - and thank goodness for this board and all the wonderful women on it! 

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Jun 1, 2011 01:13AM Kate33 wrote:

I'll PM you as soon as I find out. My PS's billing office is a bit of a nightmare so it may be a few days. Will get back to you as soon as possible, though!

Kate33 "Yes, they're fake. (@)(@) The real ones tried to kill me." Dx 12/27/2009, DCIS, 4cm, Stage 0, Grade 3, 0/4 nodes
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Jun 5, 2011 03:05PM sds3252 wrote:

Pay what you can afford on the bill until it is paid.  They cannot charge interest, from what I have been told but not verified.

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Jun 12, 2011 10:56AM VJSL8 wrote:

I'm having a problem with my insurance company too--paying for the tit-tats. My PS's office said, they have never had this denied before and are going to write a protest letter for me. Also, I know there is some Federal law about insurance companies paying for reconstruction--Does anyone know what it is? If my doctors letter doesn't work, I plan on filing a complaint with the state insurance commissioner. I've already paid the bill and it would only go against my deductible, which is $5000 and thank god, this year, I won't be close, so for me, it's more a matter of principle. Good luck.

VJ Sleight, 1st diagnosis: 1987, stage 2, ER+, 0/18 nodes, lympectomy, radiation and chemo. cancer free for 22 years, 10 months and 27 days. Dx 8/2/2010, IDC, 2cm, Stage II, Grade 3, 0/0 nodes, ER+/PR-, HER2-
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Jun 12, 2011 01:36PM Kate33 wrote:

VJSL8- I found this-

Does health insurance cover breast cancer reconstruction? WE ANSWER:

Yes, it does.

Under the Women's Health and Cancer Rights Act of 1997, insurance companies are required to cover breast reconstruction following a mastectomy, radiation, lumpectomy and any other breast cancer treatment.

The breast reconstruction will cover:

  • Reconstruction of the breast that underwent breast cancer treatment
  • Surgery to make sure that the reconstructed breast matches or is symmetrical to the natural breast (this can include surgery of the natural breast)
  • Treatment of any complications arising from the reconstructive surgery, including lymphedema
  • Prosthesis necessary for the reconstruction

This will ensure that:

  • All the stages of the process of breast reconstruction are completed.
  • The two breasts are symmetrical in appearance.

Insurance companies are required to inform you of this coverage when you enroll in a plan.

But even if this is the case, you must check with your health insurance company before you go for breast reconstruction. The doctor and the patient will have to be in agreement as to the necessity of the breast reconstruction, otherwise, it may not also be payable under the insurance.

Also, the limits specified in the policy will apply. This means that purely cosmetic and elective surgery will not be payable - this includes procedures such as nipple tattooing. 


Kate33 "Yes, they're fake. (@)(@) The real ones tried to kill me." Dx 12/27/2009, DCIS, 4cm, Stage 0, Grade 3, 0/4 nodes
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Jun 12, 2011 01:40PM Kate33 wrote:

VJS- I would try to find some threads on tit-tats, though, and post on there asking if others have had this covered by their insurance.  If they have I would try to find out what billing codes their PS used for the procedure.  The interesting thing is in the link above it states: They have to pay to make the reconstructed breast match the natural breast.  Wouldn't this include nips then?  You can't really match a natural breast without them!

Kate33 "Yes, they're fake. (@)(@) The real ones tried to kill me." Dx 12/27/2009, DCIS, 4cm, Stage 0, Grade 3, 0/4 nodes

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