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Topic: Help -- Insurance denied after TRAM

Forum: Breast Reconstruction — Is it right for you? Discuss timing and various procedures and techniques.

Posted on: Jul 2, 2007 04:48PM

pennyb wrote:

I'm just 3 weeks out from a Free Tram and received my EOB from Blue Cross (Anthem). They paid my hospital bill, but the physician's surgery charge was denied. The explanation said "Services not covered. Claim/service denied because procedure/treatment is deemed experimental/investigational by the payer". It's after-hours now, so I haven't called my dr office or the insurance company. But, I'm kind of freaking out. I thought this was all to be covered. My insurance has been great with paying for everything else. Has anyone else had this happen???

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Jul 2, 2007 06:51PM SoapMaker wrote:

Somebody must have made a mistake. Probably some new person. By law, they have to cover the recon. Hope everything turns out okay.

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Jul 2, 2007 09:22PM MargaretB wrote:

I wonder if they put down the wrong billing code. I'm sure it's a mistake. My insurance paid for almost everything.

Dx 12/23/04, Bilateral w/tram 3/10/05, DD chemo 5/12/05, finished 6/26/05
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Jul 3, 2007 01:57PM tam1953 wrote:

Have you found anything out yet?

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Jul 3, 2007 04:39PM MaryGirl wrote:

If the insurance company hasn't yet admitted to making a mistake, call the folks at the surgeon's office, and they should be happy to initiate an appeal.

dx 8/06, bilat mast w/DIEP 9/06
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Jul 4, 2007 09:04AM pennyb wrote:

I called the surgeon's office and the sec thought it was probably a mistake, but had to transfer me to the insurance lady and she was not in the office so I had to leave a voice mail message. Anxious to hear what she has to say, but no reply yet. I haven't called the insurance co. yet....thought I would talk to the dr ofc first to see if there was a problem there. I will let you know what happens. Thanks so much for your responses...I was sure it would be covered, but it just upsetting to see the EOB say I was responsible for the charges.

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Jul 4, 2007 09:37AM tam1953 wrote:

Oh Penny, I'm thinking of you. Having battled the insurance co on some issues, I know how frustrating it can be. Usually on a big charge like that, the Drs. office has it preapproved before the surgery. That's their way of making sure they get paid. Also, Drs. offices usually have a pretty good idea of what the various insurance companies approve of in their region. Keep us posted.

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