Insurance refusing because it's NOT cosmetic

Outfield

I edited this because I wasn't specific enough. 

I have a somewhat unusual complication of treatment.  I had axillary cording following surgery (BMX with ALD on the problem side), but during radiation I developed a very tendon-like structure under the skin in my axilla.  This is not the common cording - I had that too and am very familiar with the usual treatments for it.  What I've got is truly very similar in thickenss to the tendon that inserts into the outer side of the back of the knee.  My breast surgeon, the three plastic surgeons I saw, and my lymphedema therapist have not seen anything like it. 

When I'm active, which is a lot, it really bugs me.  The end of my range of motion is like a dog reaching the end of its chain, and if I do something repetetive I get sore in the area of my chest where this thing attaches.  I did months of therapy with an experienced lymphedema therapist but it didn't help.  This is not really a stretchable thing.

An in-network plastic surgeon agrees with me that this doesn't involve the skin itself, and it would be relatively simple to snip out a chunk of this.  But insurance is refusing to cover it.  I don't get it.  This is a functional issue, like a surgery I had for a torn meniscus in October, and it's directly a result of breast cancer treatment.  Does anybody have any ideas?

HantaYo

Namaste!

Axillary cording is not unusual and it is my understanding that the standard of treatment is physical therapy and not surgery.  I had cording after my BMX on the side that they took 17 nodes and my lymphedema therapist was able to treat it quite successfully.  Have you brought this topic to the lymphedema thread.  I am sure that many women there have had this too and had it taken care of with physical therapy.

Wishing you the best.

Karla

Outfield

Karla, thanks but it's not the usual cording.  There is one other woman who has been in the lymphedema forum with something similar, who is pursuing surgery in another part of the country.

LuAnnH

I'm not sure what the cording is, but if it is a medical isssue why would the insurance deny the procedure?  There may be much here I am not understanding though.

 Why not appeal the decision?  You have nothing to lose in fighting the insurance.  Get the doctor to submit detailed info on the necessity of the procedure and kick it back at them.  When your answer is "no" from the start you can't get told anything worse by apealing the decision and fight them.

Also, every state has an insurance commission, is this something that you could bring up with them?  It is a hassle for these companies to have to deal with the state insurance commissioner and they do whatever they have to in order to avoid the hassle.  Not sure if this is of any help but it's all I can think of right now.

Outfield

Luann, it is helpful, thanks.