Medicare- covers fixing an already reconstructed breast?

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Artista928
Artista928 Member Posts: 2,753
edited July 2017 in Employment, Insurance, and Other Financial Issues

Anyone know for sure if the law that Clinton passed that insurance must cover recon includes fixing symmetry since it's part of the original bc dx? I'm getting it should but have yet to find someone who had recon and needed adjusting. My right one hangs lower than the left and it's quite visible even through clothing. It's not considered cosmetic if it's tied to an original bc dx is what I've been told. Anyone been through this or know anyone who has?

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  • SpecialK
    SpecialK Member Posts: 16,486
    edited June 2017

    Yes, I have had 10 surgeries since my original exchange, only one for aesthetics, which was a fat graft. The rest were skin and allograft repairs, fat grafts to skin, new expander, new exchange, implant downsize, nipple removal - all coded as revision and all covered by insurance.

    Edited to add - your PS should be able to tell you if he/she has successfully billed Medicare for this type of revision

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  • Artista928
    Artista928 Member Posts: 2,753
    edited June 2017

    So this includes MC? Reason why I'm asking is I know MC is a tougher animal on what they view as cosmetic revision than other insurances. It's not medically necessary is what I'm afraid of and there's no precert with MC to find out. Thanks

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  • MinusTwo
    MinusTwo Member Posts: 16,634
    edited June 2017

    I believe Special is correct. It's reconstruction corrections - not cosmetic.

    The last time I saw my PS - six years after original BMX - he noticed that the side that was radiated sits up high tight. The other one is definitely saggy. I didn't bring it up, but he said "I can fix that you know". Funny. Because i wear a compression bra for LE pretty much 24/7 I really hadn't paid that much attention. Now I see it all the time. I'm not looking forward to another surgery, but I am going to explore it with him next year. He'll pretty much have to promise me that he won't touch any of my lymph system - since that's the side w/o the aggravated LE problems. (right, and we all know that that kind of promise would mean)

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  • Artista928
    Artista928 Member Posts: 2,753
    edited June 2017

    I'm just a tad nervous because should MC not cover it, no way can I pay cash even with whatever discounts I might get. I'd be one of those who went bankrupt due to medical costs and is now living in her car. I wish they did precert like other insurances do. At least you get told up front with the ICD and CPT codes if it's flat out denied beforehand.

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  • MinusTwo
    MinusTwo Member Posts: 16,634
    edited June 2017

    I think your PS will know. They certainly bill Medicare with some frequency.

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  • Artista928
    Artista928 Member Posts: 2,753
    edited June 2017

    PS wasn't 100% sure with MC with doing a lift on a non-cancer side recon. Even his biller didn't know. He's also a hand surgeon. Guess not too many MC pts have gone in for a non-medical necessary lift.

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  • Artista928
    Artista928 Member Posts: 2,753
    edited June 2017

    Does anyone mind calling your ps office and giving my case scenario to see if they have had success with what I'm looking for with MC?

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  • MinusTwo
    MinusTwo Member Posts: 16,634
    edited June 2017

    Artista - yes, I'll go ahead and call next week & ask for myself, since I'm interested in getting my left uplifted. Just to clarify - did you originally have TEs & implants on both sides?

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  • Artista928
    Artista928 Member Posts: 2,753
    edited June 2017

    Yes. Both te's at time of bmx 8/6/15 and both perm implant placement 12/9/16. Thanks!!

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  • macb04
    macb04 Member Posts: 1,433
    edited June 2017

    I had the non bc side lifted for Symmetry. Thst is part of the law, that requires it to be paid for.

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  • BlueGirlRedState
    BlueGirlRedState Member Posts: 1,031
    edited June 2017

    Any one out there familiar with challenging medicare and breast cancer? An aquaintance just starting round 4 TC, BRCA , triple negative; 2 family members died of cancer; is being told by medicare that surgery on the non-cancerous breast was "cosmetic" and is not covered. She is also really worried that they will deny payment on the reconstruction on that breast as well. She read the The Women's Health and Cancer Rights Act of 1998 (WHCRA) law on breast cancer and found out that Medicare is exempt, and that it seems to only apply to private insurers

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  • MinusTwo
    MinusTwo Member Posts: 16,634
    edited June 2017

    No, I don't believe Medicare is exempt. I think it all depends on how the doctor codes the procedures. As with all other Medicare bills, if they get one decimal point out of line, it is refused. I'd get with the doc to make sure it is coded correctly. I guessing "prophylactic" would be the term but I'm not a doc.

    I had DCIS in one side & prophy on the other and they covered everything except my yearly deductible (used to be $147.00). BMX. Labs, biopsies, Lots of scans - CT, MRI, PET/CT, expanders, and reconstruction - two hospital stays, the first for a couple of nights - anesthesiologist, etc.

    I get one or two bills a year from docs when medicare has denied. I have simply called the docs up and told them to have their billing office correct the codes and re-bill it. Don't pay anything at this point.

    Artista - per my PM, I'm working on an answer from my PS.

    Edited to say that I have Standard Medicare and a Medigap supplement through AARP/United.


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  • Artista928
    Artista928 Member Posts: 2,753
    edited June 2017

    Thank you Minus2. I too have regular MC and AARP supplement plan F.

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  • BlueGirlRedState
    BlueGirlRedState Member Posts: 1,031
    edited June 2017

    Hopefully it is a miscoding problem. She has talked to DR's nurse and a nurse navigator and they told her the DR would not code it as "cosmetic". She'll be at the clinic tomorrow, and hopefully gets it straightened out. It is another stresser now when stress is already high and chemo taking its toll

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  • Artista928
    Artista928 Member Posts: 2,753
    edited June 2017

    Hope she gets it straightened out. That's the one thing I don't like about Medicare. The don't precert their procedures like other companies do. At least with say Blue Cross they'd come out and tell you such and such isn't auth'd.

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  • MinusTwo
    MinusTwo Member Posts: 16,634
    edited June 2017

    Artista: Below is the answer I received from my PS regarding further surgery for the one side that did not have radiation and has really sagged. I'll probably make an appointment to see him later this year.'

    Yes, breast reconstruction procedures performed due to breast cancer are covered through insurance.

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  • Artista928
    Artista928 Member Posts: 2,753
    edited June 2017

    Thanks minus2. Can you ask if anyone with MC went through with it without issue? That's where my ps wasn't sure. Maybe the biller would know? Thanks!

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  • MinusTwo
    MinusTwo Member Posts: 16,634
    edited June 2017

    Artista: I'm obviously having a dumb day. What's MC?

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  • Artista928
    Artista928 Member Posts: 2,753
    edited July 2017

    Sorry, Medicare..

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  • MinusTwo
    MinusTwo Member Posts: 16,634
    edited July 2017

    That's what I'm on. Standard Medicare for parts A&B and a medigap policy that pays the 20% balance. I assume the lady at the docs office looked at my chart & knows that. I have had no issues at all.

    I do expect it depends how the doc codes the procedure. I've had several problems over the years when some dumb clerk puts the wrong code number that obviously wouldn't get paid. It's always gotten fixed.

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