insurance paying for 2nd reconstruction?

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beacher4209
beacher4209 Member Posts: 540
edited June 2014 in Employment, Insurance, and Other Financial Issues

 HELLO,THIS IS PROBABLY ALREADY A TOPIC BUT COULD NOT FIND IT. I AM PLANNING A 2ND RECONSTRUCTION THIS JANUARY 2012 WHEN I CHANGE FRON HMO TO PPO. THE REASON FOR THE 2ND IS THAT MY FIRST IS NOT SYMMETRY AT ALL AND MY MX SIDE IS VERY TIGHT AND PAINFUL BECAUSE OF THIS SIZE!TOO BIG AND GOES WAY OVER INTO MY SIDE ,WHICH COULD BE THE CAUSE OF THE AXILLARY ALSO.SO ANYWAY HAS ANYONE HAD PROBLEMS GETTING INSURANCE TO OKAY THE 2ND.IF YOU DID HOW DID YOU FIGHT IT AND IF GOT IT OR NOT? IM PREPARING FOR THE WORST....

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  • Fearless_One
    Fearless_One Member Posts: 3,300
    edited October 2011

    Hi Beacher, sorry no one has responses on this, but as I understand it, the federal law that requires insurance to cover recon (as long as it covers mastectomy coverage) provides for at least one revision.   Yours definitely qualifies as a "revision".    I would be very surprised if it did not cover.   However, with most PPO's you have a co-insurance that can sometimes be hefty.   Plus, of course, your annual deductable, whatever that may be.  

    But remember, your co-insurance is usually based on a contracted rate, not on whatever the hospital decides to charge.

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  • AnneW
    AnneW Member Posts: 4,050
    edited October 2011

    As long as the coding is correct, there should be coverage. The PPO didn't have to pay the first go-round. You're entitled to revisions, especially for pain. I would expect that a pre-approval will be necessary, and your surgeon's office should know all about the correct coding.

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  • nancyh
    nancyh Member Posts: 2,644
    edited October 2011

    AnneW is correct, they usually pay for revisions, especially if you are having problems.

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  • beacher4209
    beacher4209 Member Posts: 540
    edited October 2011

    Thank you all so much!!!! you do not know what a weight your posts have taken off my shoulders :)

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  • Fearless_One
    Fearless_One Member Posts: 3,300
    edited November 2011

    What about if problem occurs AFTER you have another insurance company (i.e. company changes insurance plans)?   Does the NEW company have to pay for it (assuming they cover mastectomies for their members) even though prior surgery was done with a different company?  

    Undecided

    We are changing companies Dec 1 so this weighs on my mind.

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  • peggy_j
    peggy_j Member Posts: 1,700
    edited November 2011
    beacher, this is a bit of a tangent but I had debated between getting a lumpectomy+rads vs. MX. My BS told me that if I chose a lumpectormy, I could always get an MX in the future and the insurance would have to cover it, mandated by law, "for any reason or no reason at all." (my BS's words). I live in CA (like you) and she implied that the law guaranteed good coverage for breast cancer related surgeries. You may prefer a more educated opinion. Earlier this year I found a CA gov't agency that helps consumers with health insurance issues. I called (about something else, BC-related) and the person I talked to was very smart, professional and helpful. 
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  • beacher4209
    beacher4209 Member Posts: 540
    edited November 2011

    Hi Peggy, could you please let me know the name of the CA gov't agency that helped you Thanks :)

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  • ibcmets
    ibcmets Member Posts: 4,286
    edited November 2011

    Beacher,

    How about www.patientadvocate.org.  (800) 532-274.  Also, the Patient Resource Bc guide has listed 4 pages of advocacy, assistance & financial need groups and phone numbers.  You can get one at www.patientresource.net or call (816) 333-3595 X 26.

    Sorry this is late, I usually stay on the stage IV, recontruction & ibc sites.

    Terri

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  • beacher4209
    beacher4209 Member Posts: 540
    edited November 2011

    thanks ibcmets i will be looking into those sites,hope you are doing ok take care

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