Need help?

cinna56

I am a 17 year breast cancer survivor.  I was 39 when originally diagnosed.    I recently consulted with a plastic surgeon on having my unaffected breast reduced to try to return some sort of symmetry.  I am really out of balance.  In my initial diagnosis it was recommended that I have a mastectomy.  I sought a second opinion from the surgeon that did the surgery to remove the tumor.  I ended up being able to have a lumpectomy and the physician was able to get clean margins when the tumor was removed-even though it had spread to 3 of the 11 lymph nodes that were removed under my arm.  I have been cancer free for 17 years.  Speed ahead-my unaffected breast is considerably larger than the one that had cancer removed.  During this consult my PS felt certain that this procedure would be covered under my insurance policy.  They sent in the needed paperwork for a precertification of coverage.  It was denied.  The physicians office has filled out the needed paperwork on my behalf for an appeal of the insurance company's decision.  In my consult my PS noted that as time progresses the situation will only get worse as far as the unbalance that I am experiencing presently.  I am so upset that after all these years I finally make a decision to take care of this problem and my insurance has denied it.  I am wondering-is there a time limit to the Women's Health and Cancer Rights act of 1998?  I am currently waiting to hear back on this appeal.  If it is denied again- what should I do? Could it be a matter of the medical coding when it was submitted?  Is there a special number that the office would use when it pertains to a past cancer patient?  I know that the number used was for a Mastopexy.  I would love to hear if anyone else has had this experience or an opinion on how I should proceed should it be denied again.

Thank you!

vlnrph

Congratulations on 17 years! By my calculation, we are about the same age - you are still very young and deserve to have this taken care of. 

My personal opinion is that, with any unusual situation, the immediate response of these companies is to say "no" and save their money. They think you will just give up & go away without trying further. It's good your doctor's office is helping in this. 

I recently appealed a precertification denial successfully (on a different procedure) so want to encourage you to not give up. If need be, your state insurance commissioner's office may become an ally. Hopefully, it will not come to that. Let us know how things turn out.