INSURANCE no longer pays for BMX? *when BC just in 1breast

I just checked with my insurance company (United Healthcare) and was told that they cover the bmx if the doctor indicates that it is medically necessary.  I just had a umx and both my BS and PS asked if I was planning on having both breasts removed, as though it were my choice, so I got the impression that it is fairly common and generally covered.  Some insurance companies may have stricter standards than others and want to see BRCA1 or 2 or at least a strong family history, and some types of bc are more likely to affect the other breast.  On the other hand, if your mother's doctor (and maybe a second opinion) says that there is no increased likelihood of cancer in the remaining breast, having it done for peace of mind should be balanced against the increased recovery time and chance of complications.  I know that I was glad I still had one arm I was allowed to use!

I also had a bi-lateral mastectomy, my choice, when I was actually a candidate for lumpectomy.  My insurance did not blink an eye and paid for everything.  However, I was Her2+ and node positive, required a separate axillary node surgery and chemo and Herceptin.  The problem with insurance paying for removal of a healthy breast is because there appears to be no reason to do it, so that is a viable reason to deny payment.  Worry is not a valid reason to remove the breast, although it was actually the reason I did it!  Turned out I had ALH and ADH in that breast, and 20 years of imaging problems and many, many cysts.  The law requires that reconstruction be covered when a breast is removed, that is why insurance must pay.  If your mom is considering a small implant and lift be aware that the lift may be a more extensive surgery than the mastectomy, and maybe more painful.  Placing an implant is most often a multi-stage process, requiring another surgery so consider that in your decision process in regards to her age and overall health.

I'm so sorry you and your mom are having added stress on too of a BC diagnosis. I think the reason insurence companies would deny your mom BMX is because of her age and possible other medical issues she might have. Any type of surgery is very risky on the body and harder as we get older. Sad to say but some surgeons won't do surgery on people after a certain age because the odds of them surviving the survey is low, (not with cancer though always surgery for that), The main concen is the heart especially if the patient has hypertension, high cholesterol diabetes ect. plus possible infection and healing issues. Removing both breast the surgery is longer and the recovery too. So since the odds are low that your mom will get BC in the other breast in her lifetime the doctor are making a medical judgment but should have explained why. Plus not sure if chemo will be part of the treatment plan but that will also be a issue. Just have the doctor go into more detail as to why its not recommended. I'm not a doctor but a cardiac RN still just generalizing don't know your mom case.



As far as reconstruction goes yes they have to cover that no matter what age if the patient wants it. Some women over 90 want breast reconstruction and some don't its hard for some woman no matter the age to live with no breast and some women in their 30's chose not too. It is a personal choice.

Here's some info on the 1996 Women's Health Care Act.

http://www.cancer.org/treatment/findingandpayingfortreatment/managinginsuranceissues/womens-health-and-cancer-rights-act

The problem you have is that it covers employer paid group plans, but Medicare is specifically not included. 

Maybe you can work out a self-pay option with the surgeon and anesthesiologist for the healthy breast, if it's done at the same time?  That's the only solution I can think of.

He is just flat our wrong that insurance won't pay for it. They may want to have the Dr say it preferable, depending on the insurance but its certainly not tru that absolutely no ins will pay! So many of us have jad it done! I would get a 2nd opinion on that one.

Since I have private insurance versus medicare, I can only speak on this front.

After 2 MRIs, 3 doc consults and a lumpectomy, I was WELL OVER my deductible.  Even if my insurance did not want to cover my bmx, they had to cover 80% of it since I did meet the deductible.  I never even checked with them...I just did what I felt comfortable with doing.

I had a BMX for ILC 9 days ago and have done great. I am 73 and medicare gave me no grief at all over the double procedure. Turns out that there was lobular hyperplasia in the "good breast" so I was very glad that it was gone. The good thing about getting ILC when you are older is that it tends to respond very well to hormone therapy and you can frequently escape chemo. I did 20 weeks of neoadjuvant hormone therapy and the tumor shrunk by over half and came completely out of the chest muscle allowing for a clean disection. I also had a total knee replacement last May and I would rather have 3 BMX than have 1 total knee. This was a piece of cake by comparison. I am otherwise healthy and active and am anxious to leave for 6 weeks in Florida 3 weeks post op. The BS sees no reason why I shouldn't go. Will do radiation when I get back. Having said that if she does decide to do reconstruction it hurts a lot more and the recovery time is longer. It is also multiple trips to the OR if you go with implants. When I was young and dumb I had implants put in and had them for over 30 years. For me it is a case of been there, done that and I have no wish to do it again. My only regret is that I ever got the implants in the first place but we don't get a do over on decisions like that.The best thing about a BMX is that I never have to have another mammogram. Woo Hoo! I never missed a mammogram in 30 years and then got the kind of BC that won't show up on one or in my case on an ultrasound either. I couldn't deal with the stress of keeping a breast under those conditions.

Crazy thought, why not find out what it would cost if you decided to pay yourself for the second breast removal. Since most of the basic surgical costs would be covered for the authorized MX I bet your surgeon could give you a reasonable price.  I know that for most the thought of paying out of pocket is out of the question, but it is possible to negotiate and discuss the actual prices for various procedures. 

I was denied by Medicare just a day ago for my prophylactic mastectomy, they called it "COSMETIC".....they did pay for my mastectomy which involved cancer......I guest being 3" away from my cancer did not count....I am really upset, as my "cosmetic breast" looks like a shar pei and medicare will receive picures and a sharp reply from me.

I had IDC

Prior to my BMX my breast surgeon said that medicare had always paid for prophylatic MX, and she has been a breast surgeon for 25+ years and has won awards in the medical community.

If you are having problems with Medicare ( A FEDERAL PROGRAM) please call the local office of your Representative in Congress and ask for help.  I suggested this to a friend who's plastic surgeon said her surgery wouldn't be covered ( my friend was 81 at the time) and her Respresentative in Congress local office got it straightened out for her in a few days. 

BTW - every memner of Congress has a local office - for help with ANY Federal Program.  You will usually find them, staff in these local offices very responsive - remember, they want your votes.

Good luck.