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Topic: Insurance Denial

Forum: Employment, Insurance, and Other Financial Issues —

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Posted on: Aug 28, 2019 10:58AM

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 28, 2019 11:55AM 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 3/27/2017 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 5/9/2017 Cytoxan (cyclophosphamide), Taxotere (docetaxel) Radiation Therapy 8/2/2017 Hormonal Therapy 9/7/2017 Arimidex (anastrozole), Zoladex (goserelin) Surgery 11/17/2017 Prophylactic ovary removal Surgery 1/30/2018 Reconstruction (left): Fat grafting, Silicone implant; Reconstruction (right): Fat grafting, Silicone implant
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Aug 28, 2019 12:16PM 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 28, 2019 12:20PM 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 1/7/2010 Lumpectomy: Left; Lymph node removal: Left Hormonal Therapy 1/15/2010 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Hormonal Therapy 1/30/2016 Femara (letrozole)
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Aug 28, 2019 02:39PM - edited Aug 28, 2019 02:59PM 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.

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Aug 29, 2019 12:39PM 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 29, 2019 12:55PM 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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