Topic: Medicare- covers fixing an already reconstructed breast?

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

Posted on: Jun 15, 2017 02:22AM

Posted on: Jun 15, 2017 02:22AM

Artista928 wrote:

Anyone know for sure if the law that Clinton passed that insurance must cover recon includes fixing symmetry since it's part of the original bc dx? I'm getting it should but have yet to find someone who had recon and needed adjusting. My right one hangs lower than the left and it's quite visible even through clothing. It's not considered cosmetic if it's tied to an original bc dx is what I've been told. Anyone been through this or know anyone who has?

Dx'd at 50. Doing it all, all by myself. Stopped Letrozole after 5 weeks. Debilitating se's. Back on Tamox now. Dx 6/2/2015, IDC, Left, 6cm+, Stage IIIA, Grade 3, 1/4 nodes, ER+/PR+, HER2-, Surgery 8/6/2015 Lymph node removal: Left, Sentinel; Mastectomy: Left; Prophylactic mastectomy: Right; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Chemotherapy 11/3/2015 AC + T (Taxotere) Radiation Therapy 5/2/2016 Whole breast: Breast, Lymph nodes, Chest wall Hormonal Therapy 6/28/2016 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 12/9/2016 Reconstruction (left): Silicone implant; Reconstruction (right): Silicone implant Hormonal Therapy 2/14/2017 Femara (letrozole) Hormonal Therapy 3/26/2017 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 9/1/2017 Reconstruction (right): Fat grafting, Silicone implant
Log in to post a reply

Page 2 of 2 (20 results)

Log in to post a reply

Jun 25, 2017 08:40PM BlueGirlRedState wrote:

Any one out there familiar with challenging medicare and breast cancer? An aquaintance just starting round 4 TC, BRCA , triple negative; 2 family members died of cancer; is being told by medicare that surgery on the non-cancerous breast was "cosmetic" and is not covered. She is also really worried that they will deny payment on the reconstruction on that breast as well. She read the The Women's Health and Cancer Rights Act of 1998 (WHCRA) law on breast cancer and found out that Medicare is exempt, and that it seems to only apply to private insurers

Log in to post a reply

Jun 25, 2017 09:46PM - edited Jun 25, 2017 09:46PM by minustwo

No, I don't believe Medicare is exempt. I think it all depends on how the doctor codes the procedures. As with all other Medicare bills, if they get one decimal point out of line, it is refused. I'd get with the doc to make sure it is coded correctly. I guessing "prophylactic" would be the term but I'm not a doc.

I had DCIS in one side & prophy on the other and they covered everything except my yearly deductible (used to be $147.00). BMX. Labs, biopsies, Lots of scans - CT, MRI, PET/CT, expanders, and reconstruction - two hospital stays, the first for a couple of nights - anesthesiologist, etc.

I get one or two bills a year from docs when medicare has denied. I have simply called the docs up and told them to have their billing office correct the codes and re-bill it. Don't pay anything at this point.

Artista - per my PM, I'm working on an answer from my PS.

Edited to say that I have Standard Medicare and a Medigap supplement through AARP/United.


2/15/11 BMX-DCIS 2SNB clear-TEs; 9/15/11-410gummies; 3/20/13 recurrance-5.5cm,mets to lymphs, Stage IIIB IDC ER/PRneg,HER2+; TCH/Perjeta/Neulasta x6; ALND 9/24/13 1/18 nodes 4.5cm; AC chemo 10/30/13 x3; herceptin again; Rads Feb2014
Log in to post a reply

Jun 25, 2017 09:52PM Artista928 wrote:

Thank you Minus2. I too have regular MC and AARP supplement plan F.

Dx'd at 50. Doing it all, all by myself. Stopped Letrozole after 5 weeks. Debilitating se's. Back on Tamox now. Dx 6/2/2015, IDC, Left, 6cm+, Stage IIIA, Grade 3, 1/4 nodes, ER+/PR+, HER2-, Surgery 8/6/2015 Lymph node removal: Left, Sentinel; Mastectomy: Left; Prophylactic mastectomy: Right; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Chemotherapy 11/3/2015 AC + T (Taxotere) Radiation Therapy 5/2/2016 Whole breast: Breast, Lymph nodes, Chest wall Hormonal Therapy 6/28/2016 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 12/9/2016 Reconstruction (left): Silicone implant; Reconstruction (right): Silicone implant Hormonal Therapy 2/14/2017 Femara (letrozole) Hormonal Therapy 3/26/2017 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 9/1/2017 Reconstruction (right): Fat grafting, Silicone implant
Log in to post a reply

Jun 25, 2017 10:24PM BlueGirlRedState wrote:

Hopefully it is a miscoding problem. She has talked to DR's nurse and a nurse navigator and they told her the DR would not code it as "cosmetic". She'll be at the clinic tomorrow, and hopefully gets it straightened out. It is another stresser now when stress is already high and chemo taking its toll

Log in to post a reply

Jun 25, 2017 10:45PM Artista928 wrote:

Hope she gets it straightened out. That's the one thing I don't like about Medicare. The don't precert their procedures like other companies do. At least with say Blue Cross they'd come out and tell you such and such isn't auth'd.

Dx'd at 50. Doing it all, all by myself. Stopped Letrozole after 5 weeks. Debilitating se's. Back on Tamox now. Dx 6/2/2015, IDC, Left, 6cm+, Stage IIIA, Grade 3, 1/4 nodes, ER+/PR+, HER2-, Surgery 8/6/2015 Lymph node removal: Left, Sentinel; Mastectomy: Left; Prophylactic mastectomy: Right; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Chemotherapy 11/3/2015 AC + T (Taxotere) Radiation Therapy 5/2/2016 Whole breast: Breast, Lymph nodes, Chest wall Hormonal Therapy 6/28/2016 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 12/9/2016 Reconstruction (left): Silicone implant; Reconstruction (right): Silicone implant Hormonal Therapy 2/14/2017 Femara (letrozole) Hormonal Therapy 3/26/2017 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 9/1/2017 Reconstruction (right): Fat grafting, Silicone implant
Log in to post a reply

Jun 30, 2017 04:36PM minustwo wrote:

Artista: Below is the answer I received from my PS regarding further surgery for the one side that did not have radiation and has really sagged. I'll probably make an appointment to see him later this year.'

Yes, breast reconstruction procedures performed due to breast cancer are covered through insurance.

2/15/11 BMX-DCIS 2SNB clear-TEs; 9/15/11-410gummies; 3/20/13 recurrance-5.5cm,mets to lymphs, Stage IIIB IDC ER/PRneg,HER2+; TCH/Perjeta/Neulasta x6; ALND 9/24/13 1/18 nodes 4.5cm; AC chemo 10/30/13 x3; herceptin again; Rads Feb2014
Log in to post a reply

Jun 30, 2017 06:49PM Artista928 wrote:

Thanks minus2. Can you ask if anyone with MC went through with it without issue? That's where my ps wasn't sure. Maybe the biller would know? Thanks!

Dx'd at 50. Doing it all, all by myself. Stopped Letrozole after 5 weeks. Debilitating se's. Back on Tamox now. Dx 6/2/2015, IDC, Left, 6cm+, Stage IIIA, Grade 3, 1/4 nodes, ER+/PR+, HER2-, Surgery 8/6/2015 Lymph node removal: Left, Sentinel; Mastectomy: Left; Prophylactic mastectomy: Right; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Chemotherapy 11/3/2015 AC + T (Taxotere) Radiation Therapy 5/2/2016 Whole breast: Breast, Lymph nodes, Chest wall Hormonal Therapy 6/28/2016 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 12/9/2016 Reconstruction (left): Silicone implant; Reconstruction (right): Silicone implant Hormonal Therapy 2/14/2017 Femara (letrozole) Hormonal Therapy 3/26/2017 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 9/1/2017 Reconstruction (right): Fat grafting, Silicone implant
Log in to post a reply

Jun 30, 2017 07:49PM minustwo wrote:

Artista: I'm obviously having a dumb day. What's MC?

2/15/11 BMX-DCIS 2SNB clear-TEs; 9/15/11-410gummies; 3/20/13 recurrance-5.5cm,mets to lymphs, Stage IIIB IDC ER/PRneg,HER2+; TCH/Perjeta/Neulasta x6; ALND 9/24/13 1/18 nodes 4.5cm; AC chemo 10/30/13 x3; herceptin again; Rads Feb2014
Log in to post a reply

Jun 30, 2017 08:36PM Artista928 wrote:

Sorry, Medicare..

Dx'd at 50. Doing it all, all by myself. Stopped Letrozole after 5 weeks. Debilitating se's. Back on Tamox now. Dx 6/2/2015, IDC, Left, 6cm+, Stage IIIA, Grade 3, 1/4 nodes, ER+/PR+, HER2-, Surgery 8/6/2015 Lymph node removal: Left, Sentinel; Mastectomy: Left; Prophylactic mastectomy: Right; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Chemotherapy 11/3/2015 AC + T (Taxotere) Radiation Therapy 5/2/2016 Whole breast: Breast, Lymph nodes, Chest wall Hormonal Therapy 6/28/2016 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 12/9/2016 Reconstruction (left): Silicone implant; Reconstruction (right): Silicone implant Hormonal Therapy 2/14/2017 Femara (letrozole) Hormonal Therapy 3/26/2017 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 9/1/2017 Reconstruction (right): Fat grafting, Silicone implant
Log in to post a reply

Jun 30, 2017 08:45PM minustwo wrote:

That's what I'm on. Standard Medicare for parts A&B and a medigap policy that pays the 20% balance. I assume the lady at the docs office looked at my chart & knows that. I have had no issues at all.

I do expect it depends how the doc codes the procedure. I've had several problems over the years when some dumb clerk puts the wrong code number that obviously wouldn't get paid. It's always gotten fixed.

2/15/11 BMX-DCIS 2SNB clear-TEs; 9/15/11-410gummies; 3/20/13 recurrance-5.5cm,mets to lymphs, Stage IIIB IDC ER/PRneg,HER2+; TCH/Perjeta/Neulasta x6; ALND 9/24/13 1/18 nodes 4.5cm; AC chemo 10/30/13 x3; herceptin again; Rads Feb2014

Page 2 of 2 (20 results)

Scroll to top button