What Will Insurance Cover Mass Removal/Reconstruction?

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Daisey4522
Daisey4522 Member Posts: 88
edited January 2015 in Benign Breast Conditions

Hello. My name is Ginger and I am 28 years old. I have an 8 cm mass in my directly under the nipple of my right breast that was found to be benign. A couple of weeks ago I went to see a Breast Surgeon and she recommended that I have the mass removed immediately. The concerns are that the mass is very large, it seems to be growing, and is directly under the nipple so there is a chance that I could lose my nipple.

The breast surgeon said that the surgery will leave me deformed because of the mass size and location and that I will need to have reconstruction. I am currently a DD and she says that she is not sure about the cup size but that it will bring that breast down to a C. She recommends that I get a reduction in the left breast because symmetry is important to me. I saw a reconstruction surgeon she recommended that same day and she recommended that I get an implant in the right breast rather than reduction in the left. I do not know how I feel about having to deal with an implant for the rest of my life so I was leaning towards a reduction, but I also hate mess with the breast that does not have a mass. I know there are other options such as tissue implant too... I'm still trying to weigh my options.

Has your insurance paid for any reconstruction after mass removal of a benign mass? The mass is so large (8cm) so reconstruction is necessary. It is my understanding that if this was a malignant tumor insurance would cover the reconstruction, even reconstruction of the other breast to create symmetry, but I am not sure since this is a benign condition. The reconstruction surgeon said that they would not cover it. Have you had surgery on a benign mass? If so, can you tell me your experience (type of reconstruction & how much you had to pay)?

It is open enrollment this week so I am able to choose a new insurance for the surgery (I do not plan to have the surgery until January so it will be under a new insurance plan). I will contact my insurance once I decide what type of reconstruction I want to do, but I would like to know if there is any hope that they will cover the reconstruction.

I would be GREATLY appreciative to hear of your experiences.

Thank you!
Ginger

PS – I did some wonderful information on this website regarding "Paying for Reconstruction Procedures" but it's not clear to me if that is only for malignant cases or if that would go for benign breast surgeries (especially in my case since the mass is so large). http://www.breastcancer.org/treatment/surgery/reconstruction/paying-for

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  • Daisey4522
    Daisey4522 Member Posts: 88
    edited November 2014

    Kayb,

    You are really wonderful! Thanks so much for this information.

    My only concern is that my breast surgeon did not mention a mastectomy… The breast surgeon is just going to remove the mass, which since it is so large, will leave me a couple of cup sizes smaller. So I'm not sure if this law would apply. I am happy to read that those who get mastectomies can have the option for reconstruction surgery.

    I am lucky I can change my insurance right now before the surgery, but at the same time I feel very rushed. I will not see the second Breast Surgeon and Reconstruction Surgeon until December (after the time I need to have chosen my insurance) so I need to try to determine what type of surgery I want to have now so I can choose my insurance company based on that.

    I'd love to hear if anyone has any experience with reconstruction after a benign mass removal.

    Thanks again! You are an amazing help.
    Ginger

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  • Daisey4522
    Daisey4522 Member Posts: 88
    edited November 2014

    We could afford a higher end insurance plan if it's going to save us money in the long run, but I'd hate to go with a more expensive plan just to find out they cover the same amount. I live in Maryland btw. I'll have to look into the laws here. There is just so much to look up with the insurance, reconstruction options, my diagnosis, etc...

    I really appreciate all of your help!

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  • Daisey4522
    Daisey4522 Member Posts: 88
    edited November 2014

    Kayb Thank you!!!! And feel free to Slueth all you want =) You have been the biggest help!

    This information gives me some hope!


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  • Daisey4522
    Daisey4522 Member Posts: 88
    edited November 2014

    Has anyone had surgery of a benign mass? Did you have any reconstruction? What did of the surger(ies) did your insurance cover?

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  • SpecialK
    SpecialK Member Posts: 16,486
    edited November 2014

    Maryland does not have state coverage specific to partial mastectomy (lumpectomy) and so reconstruction is not required to be paid for by your insurance company, even if you have been diagnosed with breast cancer.  The federal law mentioned above (WHCRA) covers required reconstruction for mastectomy only, not lumpectomy.  There are many on these boards who have had benign masses removed by lumpectomy, which their insurance company paid for if deemed necessary by their surgeon, but I think getting any recon for any resulting deformity is an uphill battle - whether it be for a benign condition or cancer.  You might have your surgeon's office ask your insurance company for a pre-treatment estimate of coverage.  Good luck!

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  • Daisey4522
    Daisey4522 Member Posts: 88
    edited November 2014

    Thanks so much SpecialK

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  • Daisey4522
    Daisey4522 Member Posts: 88
    edited January 2015

    I wanted to update this discussion thread (and my other threads) in case it helps someone, because I know reading others' experiences really helped me.

    I ended up seeing the top surgeon for a second opinion in December. WOW! That was the best decision I ever made! My biggest advice to anyone out there is be your own advocate and do your research! I always look at reviews before making any decision, whether it is to go to a restaurant or buy a particular item, so why not do this with the most important thing, your health?

    This breast surgeon looked closely at my mammogram and sonogram images and said that he did not believe it was one 8 cm mass, but that it was actually 2 masses (granted, they are still large) but he thought he could take less mass from my breast. The first breast surgeon and 2 reconstruction surgeons all told me that I would lose 2+ cup sizes or about 40% of my breast after they removed the mass(es)! This surgeon told me that since I was young, he thought I would heal well. He said with his experience what happens is he removes the mass(es), it fill with fluid and then turns into scar tissue so I should look the same. I was very skeptical because the mass(es) were so large that I could easily feel them, right near the surface of my skin, and this completely went against what the other surgeons said. I knew he was a top surgeon and had many years of experience so I decided to trust him. He said if I was not happy after the surgery we could involve the reconstruction surgeon at that point, and that insurance WOULD pay for it without a problem, unlike what the first inexperienced reconstruction surgeon told me. I also saw a top Reconstruction surgeon for a second opinion at that same hospital and he also said that insurance would pay for reconstruction.

    I had the surgery a week ago and everything turned out great! I was completely shocked that I look exactly the same as I did before the surgery! This surgeon was right, it was actually 2 large masses, not one. The incision was made around the top of my areola and is about 1.5 inches. I think because of the location of the incision, you will not be able to notice much if any scaring. They just used surgical glue (no stitches) and everything looks great.

    I have some swelling, bruising, and pain, but I expected this all and I honestly don't feel any worse than I did when I got the Stereotactic biopsy. My right nipple has been slightly inverted/retracted for the past few years but since the surgery it has become very inverted. It may be due to swelling and could resolve on it's own. I have a follow up appointment in another week.

    Also, I got the final pathology results today and both masses are benign (Nodular Adenosis). What a relief!

    I have one more piece of advice that may help someone. If you are getting a biopsy or a breast surgery where they ask you to wear a tight fitted bra, sports bra, or ace bandage after the surgery, I found a bra that works so well! It really helped keep my pain down by applying the right amount of pressure. It's called "Knockout by victoria's secret front-close sports bra". It has a double closure in the front. It would be so difficult to slide a tight sports bra over your head right after a biopsy or surgery, and a back closure bra would also be more difficult that is why I was so happy when I found this front closure sports bra. The first closure is like a regular bra that snaps in the front, then another layer zips in the front over it. They also sell one that has only the zip layer, but I found that it was harder to hold the fabric together to zip without having the inside layer option.

    Good luck to you all! This place has been a really great support for me and I hope it is for you too no matter what the outcome of your test results, surgery, etc… that have something for everyone here and I'm really appreciative.

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