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Topic: Does insurance pay for redo's & future maintenance

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

Posted on: Aug 20, 2007 11:31PM

rapidash wrote:

Will most insurance cover revisions for implant/expander surgery? Will it cover replacement of implants ten years down the road? (Boy, isn't that some optimism for a stage 3 gal!!!! ) I had a lat flap and proph. mastectomy on 6/07. Thanks for any info!! Log in to post a reply

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Posts 1 - 20 (20 total)

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Aug 21, 2007 02:14AM iodine wrote:

I don't know about 10 years down the road. My ins paid for my complete redo 1 year after my first recon.

Dotti---BE NOT AFRAID, Pope John Paul
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Aug 21, 2007 01:01PM sharebear wrote:

In Michigan insurance companies are required by law to cover any reconstruction issues pertaining to breast cancer. I had radiation after a lumpectomy and years later that breast had shrunk is size about 40% which can happen after radiation. The insurance company paid for an implant in the radiated side and a reduction on the good size in order to create symetry. All in all it took about 3 reconstructions and implant swaps to fix everything. My breasts were so dense when I was diagnosed and the natural progression of getting older plus the radiation made it necessary to exchange the implants a few times for symetry. The first one capsulized which is why we decided to do the reduction and go for a smaller implant.

Now they are both gone and the implants have been replaced with stomach muscles from a tram! Amazing! They are more symetrical now than they have every been.

Sharon
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Aug 21, 2007 04:11PM Fit999 wrote:

There was a national act passed in 1998 that requires any insurance company that covers mastectomies to cover all surgeries required for symmetry. My GS said that insurance will also cover me in the future when my natural boob sags and the implant is still high and perky. One funny thing, during my first post op checkup w/my PS she handed me the warranty card for the implant. She said since it was cancer related it�s a lifetime warranty. I read the fine print and the warranty only pertains if the implant breaks. And the manufacturer will pay up to a certain amount toward the surgery required to replace the broken implant, but the new implant would be free. Hopefully none of us will ever have to walk that road, but its good to know all the facts.

Issa
hugs, Issa Dx 12/22/2006, IDC, 1cm, Stage I, Grade 3, 0/2 nodes, ER-/PR-, HER2+
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Aug 21, 2007 04:15PM Fit999 wrote:

Dotti,

If I may ask, why did you need a redo? Ive had 4 surgeries in 7 months, I dont particulary want anymore. Im thinking by the time my natural boob sags, I wont care.

Thanks,
Issa
hugs, Issa Dx 12/22/2006, IDC, 1cm, Stage I, Grade 3, 0/2 nodes, ER-/PR-, HER2+
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Aug 21, 2007 06:36PM rapidash wrote:

Oh, I don't need a redo now! I was just wondering about later down the road

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Aug 21, 2007 06:55PM iodine wrote:

My first outcome was awful. The expander was encapsulated and never fully expanded but the ps would not admit it. I was a wuss and did't fight him, I also didn't pick him. He said he could fix everything with the exchange. The implant was under my arm, below the inframammy fold and 2 cups Smaller. He also "lifted" my good boob and made it a cup smaller to gain "symmentry".
He then denied that I was smaller and stated that he had obtainded great symmentry and was delighted with the results. He also lied to me stating that there was nothing more to do, and even there was, insurance would not cover it.

I then thought it over and let it all settle for about 3 months. Grew a spine, got a second, then third, then 4th opinion. Found a ps who actually looked me in the eye and addressed MY concerns. We took it all out and he found that I'd had a huge seroma on my mast side that had to be debrieded, a poor pocket, and then used lipo to give me an inframammary fold.
He augmented the good boob, lipoed the sides of my chest, sutured the expander/implant in place to prevent movement and I have a good outcome.
It was one of those times that when I found this doc, I was able to exhale. I didn't feel the need to second guess, reseach everything he recommended, I just did what he told me to do. I TRUSTED him. What a relief after 2 years of pins and needles.
Dotti---BE NOT AFRAID, Pope John Paul
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Aug 21, 2007 09:13PM GoodMommy wrote:

I have a question re. insurance and hope someone can answer. I'm currently with UHC through my husband's employer (he's retired). My husband is 9 years older than me and will be medicare eligible in November. In order for me to keep my insurance, he has to buy a medicare supplement offered by UHC from his former employer. This is a rip-off because he will have to pay 2 1/2 times what he could get the insurance for on the open market. I can change to a different policy through his employer because there is no pre-existing condition clause. My question, I still have to go through the exchange and nipple reconstruction. Would that be covered by a different insurance company and also would the BC be considered a pre-existing condition if God forbids, there is a recurrence?

Dx 3/2005, IDC, 1cm, Stage IIIA, Grade 3, 15/20 nodes, ER+/PR+, HER2-
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Aug 22, 2007 03:42PM slanderson wrote:

My moms insurance paid for her redo 29 years down the road.

Shannon
Shannon Dx 7/13/2005, IDC, 1cm, Stage I, Grade 3, ER-/PR-, HER2-
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Aug 22, 2007 04:01PM sharebear wrote:

I only know what is true in Michigan. I have changed insurance throught the years and through my reconstructions. We have a law that states as long as you continually have insurance and do not allow it to lapse, you do not have a pre-existing condition. If that means paying for cobra when changing jobs and waiting for insurance to kick in that that's what I've done and I've always been covered. Just don't ever go without.

Sharon
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Aug 22, 2007 04:02PM GoodMommy wrote:

Shannon,

Had she changed insurance in the 29 years? We are getting down to the wire when we can change through my husbands former employer. I know that I can't get private insurance for 10 years; but I can change to GHP or Mercy Health Care. I'm just hesitant to do anything. They will except me; but I'm afraid that they might come back and say that the cancer or finishing the reconstruction was pre-existing. I would appreciate any information anyone might have.

God bless,

Chris
Dx 3/2005, IDC, 1cm, Stage IIIA, Grade 3, 15/20 nodes, ER+/PR+, HER2-
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Aug 23, 2007 01:02AM memee146 wrote:

This is a concern for me also, my Husband is having issues with his job and I am in the middle of reconstruction. He is trying to deal with it at least until I finish recon.

I have asked several people what the pre-existing condition clause is for the situation. I have been told if there are no doctor visits for a six month period between, the change of insurance it can not be considered pre-existing.
I just hate thinking he has to deal with a job he hates, just for me to finish reconstruction.
If anyone has answers I'd love to hear them too.
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Aug 23, 2007 12:04PM Melanie53 wrote:

My Continuation of Coverage (similar to Cobra but only available for six months) will end on Sept. 30. My husband works for a small company (three employees), and I have no benefits where I work.

On Oct. 1 we can choose Mercy Healthcare Group (has no out-of-pocket limit...pretty risky)available through my husband's work, or I have to find private insurance. I don't even know if private insurance would cover the remaining reconstruction work that I need done. I have proof of prior coverage for twelve months.

I am very glad that you posted.
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Aug 23, 2007 12:15PM sharebear wrote:

Just a thought and a terrible one it is.If you decide to play the six month pre-existing condition weighting game, what if it's not a reconstruction issue and what if something comes up cancer related during those six months? That could be catastrophic. Not something we want to have to think about but definitely a concern in our world now.

Sharon
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Aug 23, 2007 12:32PM ijl wrote:

I found this link which describes pre-exsiting condition policy for most of the states. For CA it looks like as long as one has un-interrupted policy , i.e. switching from one to another, there is no waiting period for pre existing condition
Here is the link
insurance info per state
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Aug 23, 2007 12:37PM Melanie53 wrote:

Quote:
Just a thought and a terrible one it is.If you decide to play the six month pre-existing condition weighting game, what if it's not a reconstruction issue and what if something comes up cancer related during those six months? That could be catastrophic. Not something we want to have to think about but definitely a concern in our world now.

Sharon



I was thinking the same thing when I read memee's post.
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Aug 23, 2007 12:51PM kathy8429 wrote:

So if you have a mastectomy and want to do later reconstruction do you have to have the same insurance? Or would the new insurance be forced to cover under the womens health act?

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Aug 23, 2007 12:54PM kathy8429 wrote:

I would think any group helath policy would have to cover. Here is the wording of the law

On October 21, 1998 Congress passed a bill called the Women's Health and Cancer Rights Act of 1998. This law requires group health plans that provide coverage for mastectomy to provide coverage for certain reconstructive services. These services include:

Reconstruction of the breast upon which the mastectomy was performed,
Surgery/reconstruction of the other breast to produce a symmetrical appearance,
Prostheses, and
Physical complications during all stages of mastectomy, including lymphedemas.
In addition, the plan may not:

Interfere with a women's rights under the plan to avoid these requirements, or
Offer inducements to the health provider, or assess penalties against the health provider, in an attempt to interfere with the requirements of the law.
However, the plan may apply deductibles and copayments consistent with other coverage provided by the plan.
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Aug 23, 2007 01:01PM Melanie53 wrote:

Quote:
I would think any group helath policy would have to cover. Here is the wording of the law

On October 21, 1998 Congress passed a bill called the Women's Health and Cancer Rights Act of 1998. This law requires group health plans that provide coverage for mastectomy to provide coverage for certain reconstructive services. These services include:

Reconstruction of the breast upon which the mastectomy was performed,
Surgery/reconstruction of the other breast to produce a symmetrical appearance,
Prostheses, and
Physical complications during all stages of mastectomy, including lymphedemas.
In addition, the plan may not:

Interfere with a women's rights under the plan to avoid these requirements, or
Offer inducements to the health provider, or assess penalties against the health provider, in an attempt to interfere with the requirements of the law.
However, the plan may apply deductibles and copayments consistent with other coverage provided by the plan.



Kathy, I think you may have just given me the answer to my question, too. I guess I should take the group insurance, even though there's no out-of-pocket limit. I didn't realize that private insurance doesn't have to cover the reconstruction.
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Aug 23, 2007 04:51PM slanderson wrote:

Chris,

The short answer is "I'm not sure", but I do know that she and my dad have always had insurance through my dad's work. It's BCBS now. I don't know if it has always been BCBS. Also, she never had cancer. She just had fibrocystic disease and in 1978, they advised patients like this to do a preventative mast. Needless to say the reconstruction at the time was hideous. She finally got the courage up to "fix" it a few months ago and she really looks great. Insurance paid for all but $1,800.

Hope this helps!

Shannon
Shannon Dx 7/13/2005, IDC, 1cm, Stage I, Grade 3, ER-/PR-, HER2-
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Aug 23, 2007 04:55PM lvtwoqlt wrote:

I know that after my first lumpectomy for ADH that changed the shape of my left breast from a C-cup to an A-cup, the insurance paied for prostesis and bras to even out my breasts. this year I was dx with DCIS and the insurance is paying for the reconstruction after bi-lat mast.

Sheila
Women are like tea bags, we don't know how strong we are until we were thrown into hot water. Eleanore Roosevelt Diagnosed ADH Feb 2005, ADH Sept 2006 Surgery 2/12/2005 Lumpectomy: Left Surgery 9/10/2006 Lumpectomy: Right Hormonal Therapy 10/12/2006 Dx 4/27/2007, DCIS, Stage 0, Grade 1, 0/7 nodes Surgery 6/1/2007 Mastectomy: Left, Right

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