External Breast prosthesis-Dwindling Insurance Coverage

pinkpolitico1

I work and advocate for breast cancer survivors daily. We have sponsored 3 bills for survivor benefits, but we are seeing something that is unbelieveable.  All insurance companies, including Medicare, Medicaid, Veteran's Administration, Tricare are finding ways to limit or eliminate coverage for post mastectomy items and services. I wanted to know,  is anyone having problems with coverage or denials this year.

kane744

Have had absolutely no problems with Medicare coverage or denials for post mastectomy items. It is very generous coverage but I am afraid that a change in the presidency will mean big changes in Medicare coverage.

SpecialK

I was denied coverage for an external breast prosthesis by Tricare.  I was immediate recon (TE placement) from the time of BMX but had to have the left side removed two months later due to skin healing issues.  It was out for seven months.  Tricare would cover the mastectomy bra but not the prosthesis.  I believe this was due to the fact that they considered me to be in a temporary situation, but how they came to that decision I am not sure because there was no guarantee I would have success with a new TE later.  This was in the middle of chemo so I had no energy to argue with them.  I finally got a prosthesis from the ACS for free - love them for doing that!  I also have had my lymphedema sleeves denied.  They cover the physical therapy for lymphedema so they recognize the diagnosis, but not the prosthetic device to control it.  Tricare has also denied a colonoscopy requested by my oncologist post-treatment (I had a clear one four years ago), and they denied Mammaprint testing on my initial biopsy due to it being "experimental" although FDA approved.  The Mammaprint testing was written off because my BS did not get a referral prior.

pinkpolitico1

Thanks for the input.  Actually, the regulations that will begin to limit coverage are already in place.  They are being implemented at an alarming speed.  The scary part of this is that most of the other private insurances are now mirroring Medicare coverage verbatum.  Keep us up to date if anything changes!

pinkpolitico1

Hi SpecialK,  Tricare is an unusual beast.  They have implemented post mastectomy coverage changes this year that may foreshadow trends for Medicare and Private insurance in coming years.  Specifically, if you have reconstruction or are intending reconstruction, they will not pay for an external breast prosthesis.  Since Tricare, Medicare and other government groups are not subject to WCHRA 1998, the only option is additional advocacy.  The ACS is great and there are other organization out there that are beginning to do the same.  Good luck and let us know if we can help.

SpecialK

Thanks!  I have already had exchange surgery so hopefully I will not need a prosthesis in the future!  My biggest concern at the moment is the lymphedema sleeves because this will unfortunately be an ongoing need that does not seem to be covered.  You are correct - Tricare is an unusual beast!  All in all, I have few complaints - I can certainly pay for the things Tricare does not cover, and I will be eternally grateful that they paid for my extensive surgeries and chemo and Herceptin.  I am interested in your organization and what you are doing - now that I am past most of my treatment (knock on wood!) I am starting to look at what I can do to assist those following behind me - treatment inequities, for whatever reason, are so hard on the newly diagnosed.