Insurance doesn't want to pay

precious1969

Hi everyone,

I had a bilateral skin sparing mastectomy in April 2009 due to two diagnosis of cancer (one invasive , one non-invasive). After my mastectomy, I had a port placed and underwent six cycles of chemotherapy.  I finished chemo in October 2009. At the time of my surgery, I was not sure if I wanted reconstruction.  In December 2009, I decided against reconstruction.  I went to see my surgeon about removing the excess skin that was left from the skin sparing mastectomy.  He received the pre-authorization for the surgery from my insurance company (blue cross blue shield) and I had the surgery in January 2010.  My insurance company is now saying that the surgery was not covered by insurance because it is cosmetic surgery and is not medically necessary.  Has anyone else had this problem with their insurance company and, if so, what did you do about it?

Kim09

You could try appealing the decision.  The insurance company's appeal process is normally stated on the EOB's that they send you.  You also may want to check the clinical bulletin policies to see if they have one regarding this procedure.  They probably have them posted on their website.  If they do have one on this procedure you would want to refer to it in your appeal.

3monstmama

Seems to me the argument is that its part of the reconstruction process which should be covered.

Good luck!

NatsFan

Precious - contact your ps and let them know it's been denied.  You should also contact the insurance company customer service and let them know this surgery was done as part of breast cancer surgery, not just a cosmetic procedure. Recon of all kinds is required to be covered by law if you're in the US.  It may be something as simple as the coding your ps's office used - maybe they used the cosmetic surgery code for this procedure rather than the b/c recon code.  I've had a couple of issues with covered services being denied simply because the doctor's office used the wrong code when submitting the claim to the insurance company.  I've been succeesful in getting them all straightened out, generally with just a phone call.

Good luck and let us know how it goes.   

BRCA-BRAT

Hi Precious.  So sorry you are having to deal with this issue.  I will PM with more info. but have very similar experience with the same people.

concernedsis

Hi Precious

Insurance companies are a pip arent they!

Prior auth never guarantees benefits or payment - they all say that in their sleep.

A few questions for you - does your doctor ACCEPT your insurance - if so, you cannot be held responsible for the bill - only your copay or deductible - he would fight it out with your carrier.

What CPT code (procedure) did  they prior auth and what code did they bil?

What ICD9 code (diagnosis) code did they us - they did mention breast cancer, correct?

They are required by law to cover recon - removing the excess skin by definition should qualify - however they have to code for that.

Do you have a case manager you can talk to?

Good luck

EstherMSKCC

Dear precious1969,

I am sorry to hear of your situation. You should know that as of October 1998, a federal law requires insurance companies to cover all aspects of reconstruction, including operations to match the reconstructed breast to the opposite breast. As an employee of Memorial Sloan-Kettering Cancer Center, I wanted to share some resources that may be useful to you:

Insurance Appeals - Patient Advocate Foundation:

http://www.patientadvocate.org/resources.php?p=8

Breast Reconstruction Insurance Coverage:

http://www.breastreconstruction.org/breast_reconstruction_insurance_coverage.html

Steps to Take if Denied Coverage:

http://www.mskcc.org/mskcc/html/62752.cfm

I hope this information is useful...good luck with your appeal. -Esther