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Topic: Insurance Denial

Forum: Employment, Insurance, and Other Financial Issues —

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Posted on: Aug 27, 2019 08:58PM

NC5 wrote:

Has anyone had their insurance company deny coverage for a bilateral mastectomy and will only cover the breast that has cancer in it? Even after an appeal letter from my Dr and myself, they still will not cover the mastectomy for the other breast.

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Aug 27, 2019 09:55PM LeesaD wrote:

I did not have that happen but I just want to show my support for you as I find that infuriating that they would deny. I knew I wanted a bilateral mastectomy even though cancer was only in one. Many times too cancer is found in the prophylactic breast once it’s sent to pathology. It never crossed my mind that insurance could’ve denied the bilateral. I thought there were federal and state laws in place that insurance can’t do that? I’m in NY and our state laws are very good for breast cancer coverage. I hope someone with more knowledge than me chimes in and can help you.
Oncotype Score 3, 2/4 Sentinal Nodes micromestasis so pushed for ALND for 'peace of Mind' and surprise found 2/14 positive axillary nodes Dx 2/3/2017, IDC, Right, 3cm, Stage IIB, Grade 2, 4/18 nodes, ER+/PR+, HER2- Surgery 3/26/2017 Lymph node removal: Right, Sentinel; Mastectomy: Left, Right; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Surgery 4/17/2017 Lymph node removal: Underarm/Axillary Chemotherapy 5/8/2017 Cytoxan (cyclophosphamide), Taxotere (docetaxel) Radiation Therapy 8/1/2017 Hormonal Therapy 9/7/2017 Arimidex (anastrozole), Zoladex (goserelin) Surgery 11/16/2017 Prophylactic ovary removal Surgery 1/29/2018 Reconstruction (left): Fat grafting, Silicone implant; Reconstruction (right): Fat grafting, Silicone implant
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Aug 27, 2019 10:16PM exbrnxgrl wrote:

Like leesa, I have no personal experience with the situation but I understand your distress. Insurance coverage/policies vary greatly, that’s for sure.I know there are laws mandating coverage for reconstruction but not familiar with other aspects of mandated coverage.

I read a post somewhere on bco regarding a medical center that would not do a mx on a healthy breast without significant medical justification. I know that there are more than a few in the medical world who are not at all comfortable with removing a healthy body without that same medical justifications.

I had my non-cancer breast removed during my surgery but I think the surgeon and mo justified it by noting there were calcifications in the healthy breast. Since it would need frequent monitoring, removing it altogether while I was already having the effected breast removed, and recon, seemed to make sense. Maybe they can look at your mammo closely and find a calcification or two?

Bilateral mx 9/7/11 with one step ns reconstruction. As of 11/21/11, 2cm met to upper left femur Dx 7/8/2011, IDC, Left, 4cm, Grade 1, 1/15 nodes, mets, ER+/PR+, HER2- Surgery 9/7/2011 Lymph node removal: Left; Mastectomy: Left, Right; Reconstruction (left); Reconstruction (right) Dx 11/2011, IDC, Left, 4cm, Stage IV, Grade 1, 1/15 nodes, mets, ER+/PR+, HER2- Hormonal Therapy 11/21/2011 Arimidex (anastrozole) Radiation Therapy 11/21/2011 Bone Hormonal Therapy 6/19/2014 Femara (letrozole) Hormonal Therapy Aromasin (exemestane)
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Aug 27, 2019 10:20PM bcincolorado wrote:

Talk to your doctor and see if they can appeal to insurance directly. Some are willing to fight and sometimes insurance wants a "peer to peer" conversation to approve. I personally opted to not touch my non-cancer side with surgery but my PS had suggested doing it right away at the same time as the exchange.

Dx 8/2009, IDC, Left, 5cm, Stage IIA, Grade 1, 0/2 nodes, ER+/PR+, HER2- Surgery 1/6/2010 Lumpectomy: Left; Lymph node removal: Left Hormonal Therapy 1/14/2010 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Hormonal Therapy 1/29/2016 Femara (letrozole)
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Aug 28, 2019 12:39AM - edited Aug 28, 2019 12:59AM by Irishlove

Yes, I had to fight to have my supposedly healthy breast removed. I prevailed and the breast was not healthy. Medicare Advantage plan thru BCBS was my insurer and here's how we got it approved. The MO and I discussed my family history and I am not a good candidate for Tamoxifen or any AI's (I have MS). She asked if I had "Backache" and I said "Why yes I do and it's terribly painful". It was coded and notes indicate that due to my first mastectomy it threw my back out and shoulder pain. Surgery was 3 months after the first mastectomy and pathology showed Papillomatosis. You just need a supportive team and I too was surprised that it could be denied.

Surgery 2/27/2019 Lymph node removal: Sentinel; Mastectomy: Left Dx 3/14/2019, DCIS/IDC: Papillary, Left, 1cm, Stage 0, Grade 2, 0/4 nodes, ER+/PR+, HER2- Surgery 5/7/2019 Prophylactic mastectomy: Right
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Aug 28, 2019 10:39PM NC5 wrote:

Thank you all for your comments and suggestions. My doctor did have a peer to peer with the insurance company along with the appeal letters and that did not help. :

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Aug 28, 2019 10:55PM marijen wrote:

NC5, is there a reason a lumpectomy would not be enough? You haven’t posted anything regarding your status.



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Aug 22, 2021 11:21AM badmessmom wrote:

Yes, I too had that happen and I am currently trying to figure out what to do next. I chose not to have reconstruction to keep my expenses down then I was told I was denied for my left breast. I filed an appeal with insurance company stating that I was adopted as an infant and have no family history as one of the reasons for having a bmx. My Surgeon's office has someone that files the insurance and she tried talking to the insurance company with no luck. They told them they had to deny it because it was not medically necessary and I had no family history of breast cancer ( BECAUSE I HAVE NO FAMILY HISTORY BECAUSE OF ADOPTION). I just don't know what to do and who to turn to. They aren't even going to pay for my sentinel node tracer! I work at the hospital that the surgery was done and the insurance is through my work.

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Aug 22, 2021 12:22PM - edited Aug 22, 2021 12:24PM by DebAL

NC5, was it your breast surgeon or oncologist that did the peer to peer?

I won an appeal but for different circumstances but I gained an understanding of how it worked for me.

Any type of MD can be on the other end of the phone on the first appeal. Seriously, it can be a proctologist! I was stunned I was denied the first time around when my oncologist did the peer to peer. Who knows who she was talking to. It's certainly not their area of expertise. Most providers don't like doing appeals because it takes too much time out of their day. Insurance companies follow guidelines. The next step would take time on your end.

Call the insurance company and be prepared to be on hold and transferred around. Ask them to email you the guidelines for prophylactic mastectomy. The provider cannot request it must come from the patient. It's your right

Once you read the guidelines look for a loophole and write a letter based on that. Ask someone in the medical field to glance at it for you if u are not familiar with medical terminology. I also demanded an oncologist review it. On the second appeal I won. I even got the call on a Sunday.

It's rediculous that insurance companies dictate who gets care. I was so pissed. My oncologist said she has never ever had a patient win an appeal after she was denied. I've been an RN for 35 years and I'm not kidding once I'm ready to retire I would love this as a side job. Bring it on. Best wishes to you


Dx 1/22/2018, IDC, Left, <1cm, Stage IA, Grade 1, 0/3 nodes, ER+/PR-, HER2- (IHC) Surgery 2/12/2018 Mastectomy: Left, Right Surgery 2/12/2018 Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Chemotherapy 4/2/2018 Cytoxan (cyclophosphamide), Taxotere (docetaxel) Hormonal Therapy 6/14/2018 Arimidex (anastrozole) Surgery 8/9/2018 Reconstruction (left): Fat grafting, Silicone implant; Reconstruction (right): Fat grafting, Silicone implant Surgery 12/20/2018 Reconstruction (left): Fat grafting; Reconstruction (right): Fat grafting Surgery
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Aug 22, 2021 12:33PM DebAL wrote:

oopsie lol I just realized this is an older thread. I get a little fired up on this subject. Hopefully my post may help someone down the line!

Dx 1/22/2018, IDC, Left, <1cm, Stage IA, Grade 1, 0/3 nodes, ER+/PR-, HER2- (IHC) Surgery 2/12/2018 Mastectomy: Left, Right Surgery 2/12/2018 Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Chemotherapy 4/2/2018 Cytoxan (cyclophosphamide), Taxotere (docetaxel) Hormonal Therapy 6/14/2018 Arimidex (anastrozole) Surgery 8/9/2018 Reconstruction (left): Fat grafting, Silicone implant; Reconstruction (right): Fat grafting, Silicone implant Surgery 12/20/2018 Reconstruction (left): Fat grafting; Reconstruction (right): Fat grafting Surgery
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Aug 23, 2021 06:14AM Rah2464 wrote:

You go, DebAl! I also cannot believe that some insurance companies are denying the option of removing the other breast. I didn't have any issue with my insurance company thank goodness. I cannot imagine the stress that would have added to the mix . I wonder if there has been any state by state legislation to force coverage? I might have to do some checking on that.

Dx 5/23/2018, IDC, Left, 1cm, Stage IA, Grade 2, 0/4 nodes, ER+/PR+, HER2- (IHC) Surgery 6/26/2018 Mastectomy: Left, Right; Reconstruction (left): Silicone implant; Reconstruction (right): Silicone implant Hormonal Therapy 7/26/2018 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)

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