Women's Health and Cancer Rights Act (WHCRA)

Teslafied

I am eventually going to be having DIEP Flap surgery. I was scheduled to have a CT scan today - this was to check the blood vessels in my heart, abdominal and pelvic areas - my plastic surgeon ordered this. I received a call late in the afternoon yesterday from the hospital that my insurance company did not pre-authorize this and therefore, I had to cancel the appointment. I'm waiting for a call back to see why this happened.

According to the Women's Health and Cancer Rights Act (WHCRA), it states: "If WHCRA applies to you and you are receiving benefits in connection with a mastectomy and you elect breast reconstruction, coverage must be provided for:

• All stages of reconstruction of the breast on which the mastectomy has been performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• Prostheses and treatment of physical complications of all stages of the mastectomy, including lymphedema.

The first bullet point indicates "All stages of reconstruction". I have tried searching to find out exactly what "All stages" refers to. Would this include all tests performed prior to the surgery, or just to the surgery itself? The term "All stages" is so vague.

calfam04

Hi,

It's good to see that you are aware of and questioning your rights! I am new to this process after finding my own cancer following a clear mammogram. I notice that you started with a 2 cm. mass like I have. Why did you have the mastectomy after the lumpectomy? I am highly suspicious that women are being pushed to have more treatments than are necessary. I already question the biopsy procedure itself and believe it can spread the cancer cells.

I hope they repair your body well and cover all the expense!

Lisa

Beesie

Teslafied, if your plastic surgeon requires the CT scan in order to safely operate, insurance should cover it. Even though they are legally obligated to cover all aspects of reconstruction surgery, from what I've seen in my time on this site, it's not uncommon for insurance companies to start off by refusing authorization, only to provide approval as soon the patient or doctor pushes back. They know they have to pay but they try to see if they can get away with not paying.

Lisa, you mention finding your own cancer but in your other post I just read you said that you are waiting for biopsy results. Do you have the results back and have you been diagnosed? And not to answer for Telsafied, but as an FYI, while in some cases a mastectomy is medically necessary or advisable due to the size of the cancer or the pathology, in many if not most cases, a mastectomy or BMX is the personal choice made by the patient. I've been hanging around here for a lot of years and I have not seen doctors pushing mastectomies on patients unless there has been a clear medical need. More often, it's the patient who wants the MX or BMX and the doctor tries to talk her out of it or even refuses.

MinusTwo

I agree with Beesie - most women have to push to get a mastectomy as docs try to convince them otherwise. Also djmammo posted a great link & article about how biopsies don't really cause the cancer to spread.

AnnC2019

Beesie,

If you get answers please post. I am going to have diep in about 5 months I think. I also just ran into insurance issues with an approved ct/pet scan insurance payment where they didn’t pay for the necessary tracer for the scan

Teslafied

Lisa, after 2 re-excisions, the margins were not coming back clear.  I made the decision on my own to have a BMX.  I had extremely dense breast tissue, and the tumor that was found during ultrasound-neither my Dr. nor I could even feel it.  I was afraid of what else may have been hiding in both of my breasts.  Thankfully, there were no signs of cancer on the right, and no residual cancer on the left.  I’m fine with my decision.  Less worry for me in the future. 

Beesie, yes I have a feeling I’m going to be communicating a lot with my insurance company.  They originally were not going to cover my oncotype test, but after pushback from my PS and MO, they did end up covering it.  I know that the right words need to be used to make this not appear to be a cosmetic procedure, and that I have the right to have reconstruction following BMX for cancer.  I just hope that they don’t come back with something like they’ll cover an implant procedure but not the DIEP because that’s more expensive.  I should have the right to choose since it’s my body.