Insurance is denying BMX , need help!

...Oh boy am I adding this one to my "favorite topics"...

I am going to keep an eye on you, looks like we'll (hopefully) be PBMX'ers together, and the sooner the better, right?

I am currently choosing not to schedule my surgery until I get the proper codes so I know I'll be covered. The last thing I want is to be is post-op, and under the influence of pain meds, sitting on the phone, on hold for 30 minutes, holding a bill that says I owe them twenty billion dollars, and crying my head off.

So I'm not in your boat (yet) because I haven't been told "no" yet. We'll see. I'm remaining optimistic because my doctors say it should be done, and once it's done, reconstruction MUST be done. I also have Minnesota law on my side, I've researched.

If need be, I could send them a photo of my boobs and ask the insurance company "could YOU walk around like this?"  Unlike you, I have absolutely no history of breast cancer in my family. What I do have is a left breast with a giant fast growing tumor along with hundreds of fibroadenomas, and a right breast with smaller more painful tumors.

Maybe the insurance companies should consider what a favor we're trying to do for them. You, with your history, clearly are at risk. And me, with my tumors, well I have so many hiding places for cancer to hide out and stage a hostile takeover...places that can't truly been seen, even on sonogram, because of the tumors. Why don't the insurance companies understand we're NOT trying to do this for "Fun". WHO wants to get their breasts removed, just for "funsies?" I don't think so. Imagine the money we'll save them in the long run. I know that if I don't get this surgery, I'm looking at more mamos, sonos, MRIs, MBIs, Biopsies, and lab tests than they can ever understand. Add in the cost of my therapist once I go stark raving mad, and wow, it's not pretty.

Sorry about the rant...all I have to do is think about insurance and my inner snark-beotch comes out.

Where I am: I have my radiologist, and my general surgeon behind me. The paperwork has been faxed to insurance, and tomorrow a medical letter of necessity will be dictated and sent. I will stay tuned to your dilemma and wish you the best!

In the meantime, if I were you, I'd call the person you know best at your doctor's office. It will probably be a nurse or a "care coordinator". That person will be your "go-to" helper to get this surgery accomplished. Tell them you NEED someone to help you see this through. Tell them, if the doctor says it's necessary, SURELY there is another code he can place on the procedure, a code which your insurance will cover. 

Just 5 minutes ago, I got off the phone with my "go-to" girl.  I'll tell you how I knew she should be my appointed helper: I told her my insurance company said they hadn't heard anything from the doctor, and I was calling to check on things. She was shocked they told me that, because she faxed them my paperwork like 8 hours ago. BUT then, she said that it was a process, and these things take time to work their way through. She seems like I was impatiently harassing her or something. To shift her mood, I gave a meek polite little thank you, and then I apologized for bothering her, by explaining that "I was sorry for being so pushy but that my tumors have me in a lot of pain." And then I think I sounded choked up and on the verge of tears. And WOW did she sound like I was her long lost daughter in need of a mama bear's help. She started saying how she'd call to expedite, follow up, keep me informed, rest assured, hang in there, don't worry, yada yada. 

Mission accomplished.  (wink)

~ Cameron @~;~~

Here is a website that lists codes.  Maybe if you call your insurance or look on line on their site it will spell out what you need to have it coded as.  Surely your doc's have dealt with this before.  Did you talk to their medical biller?   There has to be a way around this....

 http://www.icd10data.com/ICD10CM/Codes

Elaine...don't have your problem specifically - maybe you have solved this because your post was in January but I am concerned about the financial end of this nightmare. We do have insurance coverage - at least through my husband's job. He has Blue Cross which I have to admit has been a big benefit to us. The doctor and hospital we are using are all part of the network so they submit their allowable charges to the doctors and hospital. Our out of pocket is manageable but this is only the beginning of the medical floodgate charges. The charge that really bugs me is the Womens Health Center where I had my mmgram, original and node biopsy charged over $5700 just for "using" their facility and it was more than the hospital where I had my lumpectomy. Really? I am not going to stress over the bills...we have a flex account as well but it is so telling why a lot of people dont go to the doctor. I agree you have to take on insurance companies yourself hopefully with the help of your doctors, and push, push, push them. I have no problem doing that. We are all going through difficult times; the last thing we need is financial worries too.

JBinOK, while it is true that the majority of women who develop BC do not have a strong family history, the converse is not true.  The fact that only about 15% of women who develop BC have a strong family history does not translate to "only 15% of women with a strong family history will develop BC."

For example, the average American woman has about a 12% chance of developing breast cancer. [see http://www.cancer.gov/cancertopics/factsheet/detection/probability-breast-cancer]

But women who are BRCA1 or 2 positive have a 65-80% chance of developing BC
[http://www.hopkinsmedicine.org/avon_foundation_breast_center/breast_cancers_other_conditions/family_history_breast_cancer.html]

While Elaine is not BRCA-positive, she is likely in the category of "50% of families with hereditary breast cancers" who don't have the BRCA mutation, in which case her risk is higher than the 12% average. This website says that having 2 first-degree relatives with BC increases a woman's risk by 3-fold (which would make the risk 36%) -- and Elaine has 3 first-degree relatives.  And even from a completely mercenary standpoint on the part of the insurance company, a prophylactic bilateral mastectomy and reconstruction in a healthy woman is almost certainly going to be less expensive than treating breast cancer...

Elaine, I hope the insurance review comes through for you, and I'm so sorry you're having to wait like this.

Hugs, and fingers crossed,

Ann

Elaine: are you sure you meet the criteria?  For strong family history they require a certain number and type of relatives who have been affected.  Their policy should be available online, just go to their site, go the "providers" tab and search the Policies section for "mastectomy" or "prophylactic mastectomy".  You should be able to see the criteria for medical necessity and the list of relevant procedure codes in that document (although they aren't correlated to specific things; you could search elsewhere to investigate those if you want).

BCBS-IL policy states it's considered medically necessary for high risk if: "Confirmed family history of breast cancer in two first generation relatives, such as two siblings, or mother and sister"

So, assuming your plan is similar (it may not be however)... maybe they're wanting confirmation of bc in your relatives? A letter from the doctrors may not be enough.  Have you tried contacting them directly to see what they're looking for?