Insurance Question re: reconstruction

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BostonNorthWest
BostonNorthWest Member Posts: 19
edited January 2015 in Breast Reconstruction

had dbmx in April with TEs. Had exchange in September and had a lot of divots and rippling which my PS states is the implant showing.

He suggested another procedure with fat grafting which was done on December 29.

I have just received a notice from my insurance company BC/BS that they are denying the fat grafting as they deem it experimental with the use of stem cells.

Anyone know what to do about this, it looks like a lot of people here on the board have had this procedure done, is everyone doing it via private pay. I had not expected this to be denied.

Thanks for your input


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

    Some insurance companies cover fat grafting as a "revision" to reconstruction, and some do not.  While federal law covers mandatory reconstruction if they covered mastectomy, revision surgery can get a bit trickier.  Fat grafting to correct a defect after mastectomy and implant placement has been around for quite a while, but because it is not 100% successful all the time (fat can be reabsorbed and the process repeated) your insurance company may feel leeway to deny it as "experimental".  You might ask your PS office to look at other coding used by docs who bill BCBS for fat grafting, or your PS may be able to do a peer to peer review with BCBS to further explain the need for the fat grafting.  I believe that the vast majority who have fat grafting have insurance coverage for it.  Good luck!

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  • Dogsneverlie
    Dogsneverlie Member Posts: 278
    edited January 2015

    Hi,

    BCBS did not approve my FG either but I did NOT have a dbmx; I agree with SpecialK as we have exchanged several postings on this. It could very well be the code your office is using - I am surprised it was declined as you had a dbmx. I really hope this gets approved for you. Please let us know.

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  • BostonNorthWest
    BostonNorthWest Member Posts: 19
    edited January 2015

    I saw my PS today and told him about the denial letter for the fat grafting part of the procedure, and he was shocked.

    He said he does this procedure frequently and it is definitely not "experimental' he will appeal BC/BS decision and I'll let

    everyone know as the journey continues.

    Thanks for your support

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  • alizbeth
    alizbeth Member Posts: 29
    edited January 2015

    My reconstruction surgery was initially denied.  As others mentioned, it was a coding issue.  Once that was resolved, it went through. 

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  • SpecialK
    SpecialK Member Posts: 16,486
    edited January 2015

    kayb - facing this issue now - my insurance company paid for regular fat grafting a couple of years ago when I had both implants, in a procedure to improve aesthetics by injecting the fat into divots above the implants and below the clavicle, bi-lat.  Now I have lost the left implant, after a repair surgery that went all kinds of wrong, and just had pre-authorized fat grafting in November in an attempt to improve the quality of the skin before placing another expander.  The insurance company is now dragging their heels on payment for what is a far more necessary procedure than the last one!  Go figure!!!

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  • SpecialK
    SpecialK Member Posts: 16,486
    edited January 2015

    kayb - No, I won't!  I think they will pay but I think the hold up is that this type of FG is usually used for radiation ladies - and I did not have rads, but have the same thin skin issues.  Yes, I did lose the first expander due to thin skin from necrosis.  Had three skin excisons, and removal, after the TE ruptured through the thin area on the front of the breast - not on an incision line.  I had it replaced after chemo, then filled and exchanged uneventfully.  In the spring of 2014 my PS and I determined that my alloderm was failing and perforating, so he was aware of a newer product that holds firmer called TIGR mesh.  I had surgery in March to replace the allograft bi-lat and that same thin area tore open.  Repaired in April, and a smaller implant placed, but still no healing, so implant removed in May and skin repaired again.  The thought is that FG to this area will vascularize and beef up the skin prior to another try at expander to implant recon.  I had this done in Nov. with excellent results - PS is happy but said that the insurance is pushing back.  I think they need a peer to peer, and I also have pictures of the quarter sized unhealed hole.  I happened to have an appt. with my BS (annual) and he also offered to write a letter of support for this approach.  Both BS and PS feel I need at least one more FG, but we have to make sure insurance will cover it.  The crazy thing is that they authorized the procedure in advance!

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  • SpecialK
    SpecialK Member Posts: 16,486
    edited January 2015

    kayb - lol! I sometimes stress when trying to get dressed - since I am half flat on one side and have a 650cc implant on the other side, it can be a challenge. On the whole I have been through enough with recon that I just roll with it.

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