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Topic: Family history, will insurance cover?

Forum: High Risk for Breast Cancer — Due to family history, genetics, or other factors.

Posted on: Apr 18, 2019 11:47AM

alto wrote:

I have a friend with a family history of breast cancer. She believes her insurance will not cover the cost of a mastectomy and reconstruction. I am asking these questions on her behalf:

Are there any standard guidelines insurance companies use to determine what is optional vs. necessary surgery in this situation? If family history or genetic testing show a certain result, do they have to cover surgery?

If she has concerns about genetic testing impacting her negatively by becoming part of her health record, is there a way to prove, by the number of relatives she has who have died from the disease, that she qualifies for preventative surgery?

Who should she consult to figure out what her options are? Should her doctor know? Should she contact a hospital cancer center and speak with them or their finance office, or even the American Cancer Society?

If her insurance ends up denying her, does she have other options so she's not paying out-of-pocket for surgery and reconstruction?

Diagnosed at 42. Had symptoms of Paget's for years prior to positive biopsy. No Tamox because low% ER. Dx 11/2/2018, Paget's, Right, Stage 0, Grade 3, ER-/PR-, HER2+ (IHC) Surgery 11/11/2018 Lumpectomy: Right Dx 11/29/2018, DCIS/Paget's, Right, 1cm, Stage 0, Grade 3, ER-/PR- Surgery 12/19/2018 Lumpectomy: Right; Lymph node removal: Sentinel Dx 12/21/2018, DCIS, Right, 2cm, Stage 0, Grade 3, 0/2 nodes, ER-/PR- Surgery 1/16/2019 Mastectomy: Right
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Apr 18, 2019 02:00PM gb2115 wrote:

I would probably start with her calling her insurance company to discuss.

Dx IDC in October 2016, stage 2A, 1.2 cm ER/PR+ Her2-, Grade 2, 1/3 nodes. Mammaprint low risk luminal A, Lumpectomy + radiation + tamoxifen. Age 38 at diagnosis.
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Apr 18, 2019 04:44PM edwards750 wrote:

My mother had breast cancer. My sister and I both have it as well. Family history had nothing to do with whether either of our insurance companiespaid or not. It never entered into the discussion. I have BC/BS. My sister had Medicare as her primary and a supplemental policy.

I’m sorry your friend got the dreaded DX but there are reasons to be optimistic about treatments, etc.

Good luck to your friend. She’s blessed to have a friend like you.

Diane

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Apr 18, 2019 04:52PM MelissaDallas wrote:

It varies by company. As an example, here is Aetna's guidelines:

http://www.aetna.com/cpb/medical/data/200_299/0227.html


LCIS, extensive sclerosing adenosis, TAH/BSO & partial omentectomy for mucinous borderline ovarian tumor.
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Apr 18, 2019 09:55PM vlnrph wrote:

Your friend could ask her doctor for a referral to a genetic counselor. These master degreed professionals are in the best position to analyze family history, suggest who should be tested and help interpret results.

Anyone thinking about looking for a possible inherited mutation needs to review their life, disability and long term care insurance policies before sending in a sample. We have protection from discrimination in health coverage but not those other areas. There was federal legislation known as GINA passed several years ago.

Denials can be appealed. I won on a few different issues when the company was not following their own guidelines and also because they did not honor the prior authorizations they had given!

IDC too! 🎻💊👪🐩 🇫🇮 🌹🦋 Rt MX+DIEP 4-2011; ALND 5-2011 d/t micromets; TC X 4; tamoxifen; lymphedema 9-2011; switch to letrozole 3-2014 for 1 yr; bone mets 8-2018: Zometa, rads to spine, Faslodex/Versenio Dx 3/7/2011, ILC, 2cm, Stage IIA, Grade 2, 1/25 nodes, ER+/PR+, HER2-
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Apr 19, 2019 08:58PM - edited Apr 19, 2019 09:05PM by alto

Thank you for the great responses. Since she has the strong family history but no diagnosis, we were having trouble figuring out who was the right person to go to to make a case for the surgery (oncologist, surgeon, genetic counselor), and what +/- each route might involve. I appreciate the support, leads and cautions.

It does seem to me the insurance company is not following their own guidelines (found policy info online that said multiple blood relatives with bc in direct blood line was enough) but I've also heard this insurance company skimps on coverage, so I wasn't sure how to advise her to move forward to get the prophylactic surgery she wants

Diagnosed at 42. Had symptoms of Paget's for years prior to positive biopsy. No Tamox because low% ER. Dx 11/2/2018, Paget's, Right, Stage 0, Grade 3, ER-/PR-, HER2+ (IHC) Surgery 11/11/2018 Lumpectomy: Right Dx 11/29/2018, DCIS/Paget's, Right, 1cm, Stage 0, Grade 3, ER-/PR- Surgery 12/19/2018 Lumpectomy: Right; Lymph node removal: Sentinel Dx 12/21/2018, DCIS, Right, 2cm, Stage 0, Grade 3, 0/2 nodes, ER-/PR- Surgery 1/16/2019 Mastectomy: Right

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