BC/BS: what they really denied is NO RECON AFTER LUMPECTOMY

Dogsneverlie

Besides the FG procedure, they also said they do not cover reconstruction after lumpectomies.....What is a person supposed to do?............I had two stereotactic biopsies where tissue was removed; two lumpectomies where a lot of tissue was removed and 30 radiation treatments which aided in the breast tissue shrinkage.  My left breast is HALF the size of my right breast and BC/BS is saying they don't cover lumpectomy reconstruction?

Needed to vent..........I would like to send them a photo of my breasts with one word "REALLY"????

Ugh.

sewingnut

Dogs, find out who your appeal person is and plead your case.  Send pictures, letters from your doctors, radiologist, oncologist and anyone else you can think of. My motto is "never take NO from someone who can't tell you YES". All else fails you get the media involved.

WinningSoFar

I think there is something wrong with this.  The federal law on reconstruction covers lumpectomy, as well as full mastectomy.  Google it. 

lanat

Hello Dogs,

I will also tell you that it is!   Recon, lifts and other fixes (such as fat transfer) are covered by insurance after lumpectomy, chemo and radiation.  I came on here today to check out the forum before sending the link to a friend who was just recently diagnosed with mets  I belonged to a forum 10 years ago when I was diagnosed and it was a life savor.  However, while reading through I saw your post and just had to comment.  I had breast cancer in 2004 and in 2006 I had a lift to correct and lift my breasts and insurance paid for it.  I just recently had a fat transfer to help correct the asymmetry that has happened over the last 8 years due to the radiated breast not aging normally and insurance paid again.  The reason I had to write you is because I live in MA and I noticed you live in NH.  I don't know if we are allowed to, but I would be happy to provide you the name of my PS to see if he can help you.  

SpecialK

The federal law covers mastectomy and reconstruction, but I don't believe it includes lumpectomy.  Some states have enacted coverage for lumpectomy, but I don't believe that NH is among them.  Also, coverage for correction for lumpectomy defects can be insurance policy dependent - some will cover it, some won't.   I think the best bet is a peer to peer review with your breast surgeon and BCBS, so there can be a thorough explanation of the volume of tissue removed.  If enough tissue was removed maybe then can revise the terminology of the type of surgery you have had from lumpectomy to partial mastectomy or quadrantectomy - or convince them to cover it due to the cumulative nature of all of your surgeries together.

Moderators

The inequities of rulings between States and Insurance Policies (let alone different cuntries) makes it very difficult. We hope you can obtain some consideration and fair treatment. All the best in your fight.

The Mods

labelle

A lumpectomy is in medical terms actually a partial mastectomy per my surgeon. Maybe the problem with your insurance is in the terminology. Insurance companies seem to be very fussy about how something is billed, at least mine is.  Even for something as simple as an annual well woman check-up. If it has the wrong code on it they won't pay, same procedure they'd pay for with the proper billing code. Is it possible to have your potential plastic surgeon's office see if they can get it preapproved as reconstruction needed due to a partial mastectomy? 

Dogsneverlie

Hi - thought I would provide a quick update.  HR/Benefits is going to see what they can do and I have asked my surgeon and oncologists if they would provide letters advocating for an approval for reconstruction.  I can understand a denial for the fat grafting procedure (I guess I can understand - not happy about that part of the denial because I did not want to do implants, just wanted some fill so they looked closer to the same size) but to say that my condition does not meet the medical criteria guidelines and coverage is not provided for reconstruction post lumpectomy is really disturbing.........lumpectomies deform our breasts - I am not excited about another surgical procedure and if my "cancer breast" was not half the size of my normal breast, I probably would not do anything - it disturbed me the most when I tried to purchase a bathing suit and could not, then I noticed my bras did not even fit correctly..........

Feeling sad today.

ruthbru

You could get a partial breast prosthesis to tuck in your bra even yourself out for now (BC/BS will pay for that). It took about a year & a half for my breast to settle in to it's final shape. Here's what happened to me that might be encouraging to you. I, too, was very lopsided & did get the partial prosthesis. The first summer after my lumpectomy, and even the next, was no way what-so-ever that I could wear my favorite suit (with a shelf bra). I bought another one on Lands End that had way more padding/shape plus a multi-color top to hid things. Anyway, eventually I did not need the prosthesis anymore in the bra & since I loved that first suit, I had kept it. Imagine my surprise when I tried it on just for the heck of it, and found that it again looked fine!!! So, give yourself awhile longer and maybe the same thing will happen to you. Best of luck!

Dogsneverlie

Thanks Ruth - that was a very uplifting and positive note and I really appreciate it.  I have asked for help, something I really don't like to do so now I just need to relax about it and pray that whatever is supposed to happen will happen.  That's the best we can do right?  Give it our best shot and then see where the cards fall.

Meow13

Dogs I have BC/BS too (paid after mast) however my neighbor has an indentation above her breast that is noticable in a tank top or swim suit.

She said that she would have to pay herself for cosmetic surgery. She hates the spot and to me it seems like it would be simple to fill in via fat grafting.

She is on medicare and has some supplemental and her insurance said no.

In your cases I would push for an appeal. You may have just encounter person that doesn't know.

Many plastic surgeons will say sorry I can't help you after a lumpectomy but many of them can.

Go for it.

ruthbru

BC/BS wouldn't even pay for my wig. Hair is not considered to be part of the body by BC/BS of North Dakota! I appealed it all the way up to the Insurance Commissioner to no avail, and I am still mad about that one!

 Jerky insurance company or not, I really would wait & see what your body settles into before thinking about further surgeries.

Dogsneverlie

Hi Ruth - insurance companies........grrrrr - I can't believe they would not cover your wig.  All of this is so emotional and then to feel like you are a number or a nobody.........I understand their job is to NOT pay for as much as they can, it's a business....I am rambling, I know.  Just a little frustrated.  HR told me today they copied part of our policy and sent it to BCBS - I know they are doing all they can but my gut tells me I can appeal all I want, it probably will not get me anywhere.

I have to accept whatever happens, happens for a reason.

But I can still cry about it!!!!!!

ruthbru

But it really may get better on it's own.....hang in there!

chicopeach57

I have an appt on Friday with a PS for the first time. My breast just keeps shrinking more and more and I want to do something about it. I also have BC/BS so will see what they say. My RO said they should pay according to law. I live in Georgia so we will see and I will let you know.

SpecialK

I believe that Georgia does not have any state legislation that augments the WHCRA - so they follow federal guidelines which only require reconstructive surgery for mastectomy.

I am still thinking that for the ladies who have had lumpectomy issues a peer to peer review with your surgeon and the insurance company would be the most compelling approach.

Dogsneverlie

Hi all! 

Thank you for keeping this post alive and running.  The assistant at PS office said if it gets denied again she will request a peer to peer review so we will see what happens and I will keep you posted.

SpecialK - Every time I read your posts I look at your long list of surgeries and reconstruction.  I see you had one done in May of this year - how are you feeling/healing?  I wish there was a way to select a person and "read their journey".  I see that you had implants done in 2012 and then more reconstruction and implants.

Chicopeach - YES please let me know if you get approved.

Here is a little selfish venting/ranting..........and I am sorry to do this but it's not really anything I feel that I can say outloud to a friend or colleague (that's how I know it's bad......)!  A lovely woman at work just told me her daughter got approved for breast reduction (her daughter is 16).........we have the same PS.  I understand how there are medical reasons for reduction, truly I do but for some reason I am feeling so selfish and keep thinking "really???.....I went thru two stereotactics, two lumpectomies, 30 rad treatments and they won't approve a little fill"????

I know.....not a very nice way to be thinking.....I am trying to move past it. 

On another note.....3D Mammogram on Friday at Lahey and follow up with surgeon - feeling anxious of course.

SpecialK

dogs - here is the short version - BMX with TE, developed necrosis bi-lat in scattered areas, and found a micromet in the SNB, MO and BS both insisted all the nodes out so five weeks after BMX I had ALND - yield one much larger positive node.  Two weeks later the left (non-cancer side) expander ruptured through the necrotic skin, had emergency surgery.  Two more tries within the next month to fix the skin, didn't work, so TE was removed.  Went to chemo for five months, six weeks later TE put back in.  Slow expansion (25ccs weekly) then exchange.  Had a fat grafting surgery a year after to add volume above the implants due to divots and a bony chest.  All is well for the next year, then right side bottomed out through the alloderm.  March of this year I had new allograft bi-laterally but that same bad skin area of the left side ripped in that surgery.  Repair didn't hold, so surgery again in April to repair with a smaller implant placed.  Still didn't heal, so implant removed in May.  So, I have a 650cc implant on the right and nothing on the left right now.  Because the skin is so problematic the new plan is to fat graft one or more times on the left to improve vascularity of that skin before trying another TE.  By the time I am done with this it will probably close to a year.  At one point the Mods had indicated that they were planning to add more descriptions to the surgery choices - it is a bit confusing because it looks like I kept getting the same thing done again and again.  There need to be repair options added. I probably should write a bio with this story - some people have done that so when you click on their member name it comes up on their page - I just have not gotten around to it! 

norita19

Dogs, 

I don't know if this is something you would consider or not, but here goes. I'm in a similar situation as you with one breast half the size of the other after lumpectomy and rads. I went for PS consult and after talking to him, him talking to BS, we decided to do mastectomy and diep reconstruction. It was approved by my insurance, United Health Care. I'm scheduled for 11/11. Getting very nervous but I won't miss my belly.

Dogsneverlie

Hi SpecialK - WOW, holy smokes.  Reading your short bio gave me chills. You are always so wonderful and helpful out here and when I saw all of the surgeries and everything you have been through, I just wanted to know more - you are so strong and I'm sure you have your bad/challenging days but thank you - I read a lot of posts and don't really comment a lot but I appreciate all the help and advice I have received out here.

Norita - I understand, that has crossed my mind.  It is very scary - did you have DCIS or something else?  If you want to PM me, that works too.  I think everybody out here feels of like mind, or at least the majority, that we need to do what we need to do to feel whole again.  Are you doing a double or just the one?  I am wondering how many other women out here wanted to post the same suggestion you posted but were nervous about it - THANK YOU very much for being brave.  I wasn't even brave enough to ask what people thought about that idea so truly, I appreciate it and hope that you will stay in touch.  If you don't mind sharing, will the majority of your fill be from grafting?  Maybe that is not possible with a mastectomy and you need some sort of implant as well.

MY GREAT NEWS:  I had the 3D Mammo and follow up with surgeon on Friday at Lahey and the mammo came through CLEAR so according to my surgeon, there is no further sign of cancer.  It was a LONG four hour afternoon but worth all of the waiting for the tech to read and review with the surgeon, etc.

My surgeon is VERY unhappy with how the insurance is managing reconstruction.  I am only 50 years old and no matter what happens with insurance, I will do something - even if it means saving every penny I possibly can for the next year and working out payment plans - I just can't be this way.  My appeal was denied with different verbiage - I don't have the letter with me but can you believe it was actually something like "we don't think your medical condition warrants reconstruction" - that was basically it.  My surgeon at Lahey is the Director of the Breast Health Center and she has arranged for me to meet with the Chief of Plastic Surgery on December 1 to see what he thinks can be done so I am going to try and enjoy November and Thanksgiving because at this time last year is when it all began and then regroup when I meet with the new PS and see what he has to say.

Meanwhile, my surgeon wrote an RX for me to meet with someone at the prosthesis program at Nordstroms so I will go do that and will hopefully be able to feel "normal" at my husband's holiday party.

Sad isn't it?  We go thru so much and then to have to do battle to try and feel normal again.

norita19

Dogs,

My diagnosis was 12 years ago, I had IDC and 9 positive nodes, chemo, rads and 5 years of tamoxifen/aromasin. At this point the mastectomy isn't totally "medically necessary" but it's the way I can get a proper reconstruction. I'm just doing one. I'm having the DIEP procedure where they take a section of fat with it's blood supply from the abdomen.

Dogsneverlie

Hi there! Still in the "waiting" game.......received an email from PS that the person who supplies the medical equipment is going to see what he/she can do? I have no idea what that means...........

Still meeting with Lahey PS on December 1 and will see what he has to say. Trying to bask in my good news mammo.

I am wondering if the Lahey PS has another option that insurance will approve.....going to read up on DIEP for lumpectomies if such a thing even is an option.

Thank you for your comments and support, I truly appreciate them.