BUPA won't pay for cavity shave surgery, is this right?

Steely

Hi,

First to explain our experience, my wife had lumpectomy surgery which was followed by three cavity shave surgeries, during the second cavity shave another small lump was discovered and removed, but still the margins were not clear, at this point the consultant gave my wife the option of one more cavity shave or a mastectomy, my wife chose the cavity shave and it was clear.

This was all covered by the good old NHS, but as my family are covered by my employer through Bupa, we decided to claim the hospital allowance for each surgery, Bupa's breast cancer leaflet states that they will cover surgery to remove breast cancer, so we submitted the forms for one lumpectomy and three cavity shaves.

Bupa have written back stating that they will only payout for the initial lumpectomy surgery, claiming that according to the BUPA associate medical director, a cavity shave is preventative rather than required to treat the cancer, they don't' cover preventative surgery, a cavity shave is not available through Bupa.

They also claim that cavity shaving is part of an ongoing clinical trial, and trials are not covered by Bupa.

Two things on my mind;

1) I can't find any evidence that it is part of an ongoing trial, this type of surgery seems to be normal practise within the NHS and elsewhere, and is mentioned as a procedure in the NHS breast cancer information, both on-line and in written format.

2) At no point was my wife given a choice regarding this extra surgery, it was explained as necessary to completely remove cancerous tissue, she was not told that it was trial surgery, the people in the NHS cancer centre certainly don't seem to think it is either.

I have since found information regarding trials that involve taking more tissue at the lumpectomy removal stage, to potentially reduce the likelyhood of requiring further surgery, but that doesn't include the procedure itself so shouldn't be relevant.

I thought the point of removing the cancer in the first place is to assist your future health prospects (like any surgery), so removing all the cancer seems like a reasonable thing to do, it is surgery to remove "the" cancer.

Do you think we have cause to complain to the financial ombudsman service who regulate health insurers?

Has anyone else had the same or similar experience?

Thanks,

Paul & Kerry.

Moderators

Dear Paul and Kerry,

Welcome to the community. We hope that you will gather helpful information and support from our well informed and compassionate members. Here is some information on our site about Cavity Shave with links to The 2015 ASCO meeting. WE don't know if this will be helpful in your communication with the financial ombudsman. We hope that others will respond. Please stay connected here and keep us posted on what you learn.

The MOds

vlnrph

Yes, do appeal this denial; file a grievance; complain to the ombudsman; follow whatever procedure is described by your National Health Service/the other company in order to achieve a review. As kayb mentions, here in the U.S., insurance providers are very quick to say no (it's how they keep enough money to remain profitable!) but you have a right to receive benefits. Let us know how it turns out...

Steely

Thanks for the replies. Terminology did cross my mind, my wife mentioned it to the helpdesk but it fell on deaf ears, I will certainly talk to the consultant about the terminology and getting something in writing that excludes the words cavity shave.

april485

I had to have re-excision surgery and it was fully covered but I am in the US. I do agree that it is likely a matter of what words were used to describe the surgery rather than trying to achieve clean margins. APPEAL for sure! Best to you!

sas-schatzi

Steely, yes, appeal it with the help of the Docs, plus, Your words " during the second cavity shave another small lump was discovered and removed, but still the margins were not clear, at this point the consultant gave my wife the option of one more cavity shave or a mastectomy, my wife chose the cavity shave and it was clear" Margins weren't clear after the second shave. That was not known until after the 2nd pathology was done. The second pathology indicated they're were still cancer cells present. A third procedure was "Medically Necessary" to obtain acceptable margins. The pathology done after the third procedure showed acceptable margins. The pathology reports are key to getting approvals even if the coding was screwed up.