Insurance and proth/bras then recon?

My insurance covers a certain amount of $$ for durable goods each year and does not care how you spend it, as long as it's purchased from an "in network" medical supply store. You should check about your specific benefits.

Wish, the prosthesis and mast bras are "durable goods" (durable medical equipment), and are usually covered under the Major Medical part of an insurance policy.  They're considered "durable" because they last and are not disposable, like gauze bandages.  That's important.  Apparently, some insurance companies and Medicare are really picky about the distinction.

No, recon is not a "durable good."  Well, okay, it is; but it's a surgical procedure.  I don't know what my very good BC/BS plan does about delayed recon--I never asked.  I just got my first prosthesis and 2 mast bras.  My plan covers one prosthesis and 4 bras per year; more may be covered if documented as medically necessary. 

Could you call your insurance company and ask them?  Really, the price difference is so huge:  ~ $300 for a prosthesis + ~ $40 per bra, versus $100,000 (+/-) for recon.  I can't see why they would quibble about having paid for a fake plastic boob and then covering the cost of a reconstructed one a year or two (or more) later.  YMMV, though.

otter 

YMMV = your mileage may vary (i.e., your situation might be different from mine).

YOU NEED TO GIVE THE INSURANCE COMPANY THE CODE FOR RECON so they can look it up???  Good grief.  Tell them to do their job.  Okay, I guess normally they would not have to know the code, because it's given to them by the "provider" (surgeon, pharmacist, DME ( = durable medical equipment) supplier, etc.), when the claim is filed.

Um, I just realized--maybe a breast implant is considered "durable medical equipment"?

There is an insurance code for each procedure and for some of the materials needed.  You can sometimes "google" the procedure to find the code.  For example, you might try "breast implant" x "insurance" x "code", or "breast" x "TRAM" x "code".

I keep getting different numbers for the same thing, though.  How about asking your surgeon's billing office what code they would use?  That's what I had to do to find out the codes for my LE sleeve and gauntlet.  My insurance company couldn't tell me what my allowance was for LE compression garments unless I could give them the code.

<sigh>

otter 

Wish, When I had my first lumpectomy in 2005, I was lopsided and my doctor gave me a script for mast products. I too called the insurance (BCBS) to find out how many bras I qualified for and they asked for the cpt code. I didn't try to get the code but the woman who I went to for my fitting was familiar with most of the insurance companies and what they would cover. She was able to get me 6 bras and 2 prost. It was early in the year and I had not met my deductible yet so I had to pay 300 for all of it. If I had met my deductible she accepts what the insurance pays as full payment. 

In 2007, I was dx with DCIS and opted for bilat mast, my insurance covered the full cost of the recon, with a few appeals for the use of alloderm. I checked with my fitter and she has a 'form closet' for returned forms that she gives to uninsured women, so I am going to donate my prost to give to the uninsured women. (I am wearing them this year and a blonde wig as part of my Dolly Parton costume for Halloween)

Sheila

My first claim for prost was with BCBSMI, we were under the umbrella from the corp office in Monroe MI, but in 2006 the insurance changed to local BCBS so now I am under NC. A lot of what they will or won't cover does have to do with your particular policy. We are self insured but administered by BCBS. As I said, the woman who does my support group fittings has been doing this for 20+ years and knows what the different companies will pay for and if she files it under different codes, she can actually get a couple of extra bras a year. I let her do the filing or I would know the codes.

Sheila

Under federal law and NYS law, insurance companies must pay for a successful reconstruction, and it does not need to be immediate.   WHAT they pay can be an issue to the plastic surgeon.  But the reconstruction must be complete and sucessful, so if implants fail, the insurance must go on and pay for tissue reconstruction, or once the reconstructed breast is done, the insurance must pay for adjustments to the other natural breast to achieve symmetry.

Here is a link:

http://www.plasticsurgery.org/patients_consumers/links_resources/Breast-Reconstruction-Resources-1998-Federal-Law.cfm