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Topic: Does OHIP cover surgery for both breasts?

Forum: Canadians Affected by Breast Cancer —

Canadian health care, clinical trials, and life in general in the north.

Posted on: Jun 17, 2011 02:07PM

Diane31 wrote:

I will be having breast reconstruction and will be seeing my plastic surgeon in December.  Does OHIP cover the cost of both breasts or only the one getting done. 

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Jun 18, 2011 11:43AM dlb823 wrote:

Bumping for Diane...

Deanna "The soul would have no rainbow if the eyes had no tears" Native American proverb Dx 2/1/2008, 1cm, Stage IIA, Grade 3, 1/16 nodes, ER+/PR+, HER2- Dx 1/3/2014, Stage IV
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Jun 18, 2011 12:16PM crazy4carrots wrote:

Diane -- Your surgeon will know for sure, but I was assured (when considering it) by a plastic surgeon that reconstruction on both breasts is covered, to ensure a "matching set".  Surgeon was going to do a "lift" on my remaining breast, BTW.

The demagogue preaches doctrine he knows to be untrue to men he knows to be idiots. Dx 1/10/2008, ILC, 1cm, Stage I, Grade 3, 0/4 nodes, ER+/PR-, HER2-
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Jun 19, 2011 08:35AM Diane31 wrote:

Thank you for your reply lindasa.  I am glad since I would like my other breast to have a lift.

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Jun 23, 2011 11:48AM FellowCanadian wrote:

Hi Diane,

My "bad" side and my better half were both covered by OHIP - many surgeries over.

FellowCanadian
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Feb 8, 2012 08:47PM jparmentier wrote:

Can you tell me where or who the surgeon was? I am getting a completely different story from my plastic surgeon than when we first started this. Now he says.. the " other" breast will cost me about $4,500...

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Feb 8, 2012 09:17PM Beesie wrote:

I had a single mastectomy but as part of the reconstruction process I had an implant added to my other breast to provide a better match.  All costs were fully covered by OHIP.

Here's what the University Health Network website says about this:

If you desire either a lift or reduction or augmentation of your opposite breast, then your plastic surgeon will apply to the Ministry of Health to have this procedure covered by OHIP. This process can take upwards of 3 months. 

www.breastrestoration.ca/breas... 

My PS never mentioned anything about pre-approvals to me, either because it wasn't necessary at the time my surgery was done or because the approval is just a rubber stamp (which I'm sure it is).  I didn't have the implant added on the other side until my exchange surgery, which was more than 6 months after my mastectomy so there would have been plenty of time to get the approval.  I'm not sure if the same pre-approval is required for a prophylactic mastectomy done together with a required mastectomy, and if it approval is required, how the timing would work.  I do know that quite a few women here have had bilateral mastectomies, with one side being prophylactic and the costs have been covered - with no issues or problems - by OHIP.

“No power so effectually robs the mind of all its powers of acting and reasoning as fear.” Edmund Burke
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Feb 8, 2012 09:28PM - edited Feb 8, 2012 09:30PM by jparmentier

This Post was deleted by jparmentier.
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Feb 8, 2012 09:33PM - edited Feb 8, 2012 09:35PM by jparmentier

Thank you so much. What you had done is exactly what was explained to me as the route we were going. Then the story changed completely. What surgeon did you use? I am in Mississauga,Ontari, by the way. 

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Feb 8, 2012 09:53PM Beesie wrote:

I had my surgery at Princess Margaret Hospital, which is part of UHN.  My surgeon was Dr. McCready.  My PS was Dr. Lipa - she left shortly afterwards for California but she's now back at Sunnybrook.

Who is the doctor who is telling you that this is an out-of-pocket cost? 

“No power so effectually robs the mind of all its powers of acting and reasoning as fear.” Edmund Burke
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Feb 8, 2012 10:32PM Cat123 wrote:

Yes!  OHIP covers both boobies!

Cat123 Dx 7/29/2010, IDC, 6cm+, Grade 3, 4/17 nodes, ER+/PR+, HER2-
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Feb 8, 2012 10:40PM jparmentier wrote:

Dr. Micheal Weinberg..well respected well known surgeon with unbelievable credentials...zero bedside manner. Thank you sooooooo much for all the info everyone. I went to the website got all the info I need and cancelled my appointment with Dr. Weinberg and said I will be going elsewhere. Thanks a million!!!!

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Feb 9, 2012 06:08AM sling99 wrote:

Wow, chief of plastic surgery...Wall of SHAME!

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May 9, 2013 11:48AM Ninny66 wrote:

HELP! It is 4 years and 11 months since my lumpectomy. After surgery my breast was a little smaller than the other but it didn't bother me enough to do anything about it. After 2 children and Breastfeeding (on my "good" breast) the difference between my breast is now noticeable. I went to see a very highly respected surgeon and was told that he could do an implant on the side that had the lumpectomy and a lift on the other. I asked if I could have an implant on both sides. I was told that OHIP only covers the implant on the affected side and a lift on the non affect. An implant on the non affected side would cost $6000 extra. After reading some of the posts on this site I realize that his information may be wrong. Could someone please tell me which surgeons will do the implant on both sides covered by OHIP. I don't have the money for plastic surgery as I went bankrupt trying to have children after chemo ruined all my eggs and had to find an egg donor and do IVF. I figure after all I have gone through I at least deserve nice boobs!!!

Thanks

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May 9, 2013 02:37PM hrf wrote:

Probably best to speak to a surgeon who specializes in breast surgery following cancer. In Toronto there are at least 3 main clinics. At Sunnybrook, at Toronto General, and at Women's College.

BRCA2+ first dx in Oct. 2004 2nd dx Feb. 2009 a new primary
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May 10, 2013 09:00AM Ninny66 wrote:

The surgeon I spoke to does do quite a bit of breast reconstruction surgery. He works out of Humber River but did training at a world re-owned cancer hospital in the US. But I will try to get a referral to Sunnybrook. I'm pretty sure the surgeon that did the lumpectomy works out of there even though I had the surgery at Women's College.

Thanks for the advice.

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Jul 10, 2013 05:49PM Alldone wrote:

Hi there. Mine was covered at Women's college hospital ....however i did have a letter from my genetic oncologist who supported prophylactic mastectomy of the right breast due to strong family history Altho no BRCA issue. DR Semple is amazing. Very experienced so if u get in for a consult he can advise.
I had a mastectomy done of myleft breast in Peterborough fall of 2009 then chemo and radiation. Researched for plastic surgeons and chose Seme. He recently did a fat graft technique to repair the radiated skin then expander, implant and recon areola and nips. Was 5 th one he did for this new procedure using the fat graft to re stimulate stem cell growth to repair the damaged tissue. This is 'new' and many r coming from around the world to train under him.
For the prophylactic mastectomy of the right side he reconstructed at time of mastectomy using implant and alloderm. Did areola and nipple reconstruction on both sides 11wks ago.
I would recommend u get more info on what's new and available to u. I hear Dr Zhong is Also good as a friend went to her. Good luck.

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Feb 26, 2014 02:02PM Dale_Braks wrote:

Hello there,

I just joined today.  I am thinking about reconstructive surgery following mastectomy.  I am getting conflicting information.  I have been told that full OHIP coverage is limited to within 2 years of your surgery (mastectomy).  I asked my onchologist and she said there is no time limit.  Does anyone know for sure if there a timelimit. 

I don't want to miss it if there is.  Thanks.


 

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Feb 26, 2014 03:30PM Diane31 wrote:

There is no time limit.  I had my reconstruction Sept( 2012) done 5 years after my mastectomy(2007)  I just had nipple reconstruction done 3 weeks ago and all of this was covered under OHIP.

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Feb 28, 2014 10:23AM - edited Feb 28, 2014 10:24AM by Dale_Braks


Thank you Diane31.  I am going to see a surgeon soon.  Smile

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May 8, 2014 07:36PM hrf wrote:

Me too. I had reconstruction 5 years after bmx. Just had nipples done last week. Everything fully covered by OHIP

BRCA2+ first dx in Oct. 2004 2nd dx Feb. 2009 a new primary
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Jun 14, 2018 08:53AM Kanadierin wrote:

i just saw my plastic surgeon and he said I have to pay for the implant in the breast that had no cancer. Can anyone advise us. I calked OHIP and cancer foundation and no straight answers. Bad enough to have cancer, now they want money

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Jul 26, 2018 10:07PM - edited Jul 26, 2018 10:13PM by Amica

This Post was deleted by Amica.
1998 Stage 2 IDC,1/16 nodes, ER/PR +, HER2-,Gr 3,finished tx 2010--Stage IV dx Aug 2018 sub-pectoral lymph nodes, Ibrance/Letrozle/Prolia. Dec/19 Mets Liver, Tamoxifen until Mar/20 mets progression, now on Faslodex only
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Aug 5, 2018 09:16AM Kanadierin wrote:

Where did you get your info

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Aug 5, 2018 10:23AM moth wrote:

Kanadierin - on p. 18 (at the bottom) of this OHIP cancer surgery guideline it discusses prophylactic mastectomies. I'm interpreting it to say that for a person to be covered, you need pre-approval and designation as high risk. I think if they designate you as high risk, then the mastectomy & reconstruction are covered, even if it's delayed. http://www.health.gov.on.ca/en/pro/programs/ecfa/d...


Feb 2020 - Stage IV, mets to lung, liver, mediastinal lymph. Dx at 50 in Dec 2017; Left, IDC, 1.7 cm, Stage I, Grade 3, 0/5 nodes, TNBC Surgery 12/12/2017 Lumpectomy: Left; Lymph node removal: Sentinel Chemotherapy 2/14/2018 AC + T (Taxol) Radiation Therapy 8/13/2018 Whole-breast: Breast Chemotherapy 3/18/2020 Taxol (paclitaxel) Immunotherapy 3/19/2020 Tecentriq (atezolizumab)
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Aug 5, 2018 04:29PM moth wrote:

Kanadierin, just got this info:

These are the OHIP payment guidelines. On the following webpage, the reader needs to click on the blue line "Physician Services Under the Health Insurance Act" to bring up the PDF. http://www.health.gov.on.ca/en/pro/programs/ohip/s...

On page 608 of the PDF, it says:

14. Breast Surgery

a. Post-mastectomy breast reconstruction See listed services for payment requirements related to post-mastectomy breast reconstruction.

Commentary:

1. Unilateral or bilateral breast reconstruction is an insured service when the procedure is subsequent to any mastectomy procedure performed on a female (including wedge resection).

2. Unilateral augmentation mammoplasty in association with post-mastectomy reconstruction of the contralateral breast is an insured service.

3. Unilateral reduction mammoplasty in association with post-mastectomy reconstruction of the contralateral breast is an insured service.

4. Prior authorization of payment is not required for balancing unilateral augmentation mammoplasty or balancing reduction mammoplasty in association with post-mastectomy breast reconstruction.


b. Augmentation mammoplasty (other than post-mastectomy breast reconstruction)

i. Augmentation mammoplasty when performed for reasons other than post-mastectomy breast reconstruction of the contralateral breast is only insured for the following conditions and when prior authorization of payment is obtained from the Ministry of Health and Long-Term Care:

. a. breast aplasia;

. b. severe unilateral hypoplasia of the breast; or

. c. gross disproportion.

ii. Only a unilateral procedure (i.e. augmentation or reduction mammoplasty) is insured when performed solely for gross disproportion.

Feb 2020 - Stage IV, mets to lung, liver, mediastinal lymph. Dx at 50 in Dec 2017; Left, IDC, 1.7 cm, Stage I, Grade 3, 0/5 nodes, TNBC Surgery 12/12/2017 Lumpectomy: Left; Lymph node removal: Sentinel Chemotherapy 2/14/2018 AC + T (Taxol) Radiation Therapy 8/13/2018 Whole-breast: Breast Chemotherapy 3/18/2020 Taxol (paclitaxel) Immunotherapy 3/19/2020 Tecentriq (atezolizumab)
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Aug 17, 2018 11:50AM SideBoobs13 wrote:

Hello,

I'm not sure if you still active on this website or not but if any chance you check out your mail box,

Please, respond to my question regarding NIPPLES REPOSITION.

I had a bad breast implant procedure that messed up my breast appearance.

I would like to know the PS who's taking care of you.

Is it covered under OHIP ?

Thanks

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Mar 17, 2019 08:15PM Masectomy0119 wrote:

I had a partial mastectomy a couple months ago. They removed a mass over 8cmx5cmx4cm approx. fortunately it was not cancer - something called PASH. My breasts are now not the same size however I’m not too concerned about it. I do want to know my options though as I would love to get it fixed and lifted if it’s all covered by OHIP. Does anyone have recommendations of who I should contact ? What doctors are good in Toronto? I don’t think my surgeon would recommend it as they are not that bad but I kinda want to know if it’s an option for me. Anyone have suggestions ? Do you know if it will be covered by ohip now that results came back and it wasn’t cancer / PASH?

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Mar 18, 2019 06:26AM Beesie wrote:

A partial mastectomy is medically the same as a lumpectomy (although the amount of tissue removed may be larger) and the coverage rules for a lumpectomy would apply.

To the post above, this is the line from the OHIP guidelines that would be relevant in your case:

ii. Only a unilateral procedure (i.e. augmentation or reduction mammoplasty) is insured when performed solely for gross disproportion.

So if you are looking to only have the affected breast done, I believe that OHIP would cover this. Although your diagnosis wasn't cancer, if the surgery was medically required (i.e. not a cosmetic procedure) and was done to remove a high risk condition and determine whether or not cancer was present, I think you would be covered.

As for surgeons, the best are at the hospitals - Dr. Lipa at Sunnybrook, Drs. Hofer, Zhong & O'Neill at UHN, Drs. Semple & Brown at Women's College - probably not a complete list, but those are the ones that come to mind. The problem is that because these doctors prioritize cancer patients, it can take years to get in to see them. I believe that Dr. Mitch Brown has his own private practice as well (I don't think the others do) so the wait might be shorter this way. Dr. Lipa was my PS 13 years ago when she was at PMH; immediately afterwards she moved down to California and recommended that I see Dr. Kyle Wanzel if I required any follow-up. I've met him but have never had any surgery done so I can't vouch for him, but I expect he must be pretty good if Dr. Lipa recommended him. Hopefully others come by with recommendations.

You will need a referral from either your GP or your breast surgeon to get in to see any plastic surgeon.

“No power so effectually robs the mind of all its powers of acting and reasoning as fear.” Edmund Burke
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Mar 25, 2019 05:55AM Masectomy0119 wrote:

Thankyou so much for the information. I really appreciate it!

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