Insurance coverage for prophylactic mastectomy

I do not have the gene.  Nor have I have been dx.  I have a strong family hx and have had several lumpectomies and biopsies.  They recently started finding atypical cells.  My insurance covered a complete bilateral mastectomy with all reconstruction with no issues at all!

PeggySull, I had a bilateral, one cancer, one proph.  Under WHRCA (think those are the right initials) federal law, if insurance covers mastectomy, under the law they MUST cover all phases of reconstruction including surgery on the other side to achieve symmetry.  I do not have the gene.  Under the same law the insurance covered the removal of the dog ears in the middle of my chest which were caused by the BMX and prevented wearing prosthetics.  In both surgeries the end result for me was to be flat which is what I wanted - to be done with the least amount of time on the table, risk and recovery.  You could opt for full recon if you wished.  These things must be appropriately coded and you need to absolutely do not take No for an answer.  It is not uncommon for insurance to deny and hope you will go away - Don't!!

Sometimes the bigger fight is with the breast surgeon. Some will not argue with you and some will.  Whatever decision you come to in that quiet place in your heart, stand your ground.  After all it is you who will live with the decision and therefore it should be you who makes it.

Barbara

I recently had a umx, but both my surgeons asked if I'd considered bmx, so I assume there's usually no problem covering it.  You can generally call your health insurance or there may be a rep where your husband works who can snswer questions. 

Hi pamalot - My BS's nurse requested my preventive surgery from my insurance co. It only took a few days. If I were you I would not rush into surgery until you've had a chance to figure out exactly what you want. You might repost this on the surgery or DCIS forum. I know many of the ladies have a lot of experience regarding insurance coverage (I'm assuming you're in the US.)

Hi pamalot. I'm going into the prophalac, insurance try also. I have posted the question also. My ins is bcbs of alabama. I had right uni mx 4 yrs ago, but just wasnt sure if I should remove other breast even though my bs said he felt I should. Anyway, my ps did say its about the way its coded. My ins has lots of fine print that you have to call for, but I am going to let my bs and ps go for it. I know they cant refuse to recon the mx and any work to the other for asymmetry. They may try to pull the gene test thing on me, and I cant afford it, so we'll see. All we can do is say...here goes! Btw I do not really care for my onc, he's a head petter, so I hope he's not going to be a wrench in it all

My PBMX was initially denied by BCBS - MA.  My BS did a peer-to-peer and got it approved. On the paperwork I received from the insurance company notifying me that they had overturned their original decision, it stated that my doctor had provided office notes and pathology reports in support of the case, and that the surgery was approved due to rapidly growing, bilateral breast masses.

Of course I got the denial notice on a Friday and had to stress out over it all weekend.