HELP! Anyone have BCBS deny bi-lateral Mastectomy?

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Marymac5522
Marymac5522 Member Posts: 14
edited August 2017 in Triple-Negative Breast Cancer

ONE business day before insurance the doctors office calls and says my insurance, BCBS PPO plan (standard version for Federal Health care plan... the most expensive insurance option to Federal Employees... the premier? plan has denied having a bi-lateral mastectomy and reconstruction. They will pay for the side affected by breast cancer only. As far as I can tell there is a law that says they have to pay for reconstruction to make both breasts look symetrical, however they don't have to pay to remove the second breast if THEY determine it is not necessary. They have said since I am not BRCA positive it is not necessary. I am the 9th occurance in 6 women (aunts and cousins) of my family to have been diagnosed! One was diagnosed at age 40, the others later in life. I am 62. It is familial genetic but not a gene that has yet been isolated. The left side was diagnosed as invasive ductal, fast growing, TRIPLE NEGATIVE. It is luckily small (about 1/2 cm). I am sure the hospital agrees that this is best as they are a premier breast cancer center (who treated 1 aunt and one cousin).

We have made complex arrangements to travel out of state to this hospital because we trust them and they are participating in our BCBS plan etc. They treated one aunt and one cousin and advised another cousin to have bilateral at age 42 because she's is just playing a waiting game (she hasn't yet). The reason I even want to do this is because, of the 6 women, 3 tried to save their breast and did radiation and chemo... guess what? All three had recurrence! I don't want to mess around. I agonized over this decision and now I find this out?

I know I can appeal, I can call/write my congressman, etc. But before I start the urgent last minute phone calls... does anyone have some "magic words" I can utter that will help my case?


Thank you!

Mary Mc

age62, triple negative, invasive (probably stage 1ish). lumpectomy July 2017 found stage zero and second opinion on biopsy found invasive and triple negative

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Comments

  • wrenn
    wrenn Member Posts: 2,707
    edited August 2017

    My doctor asked what I wanted and I wanted bilateral even though cancer was in left breast. Reading pathology she said she was glad I made that choice because there were pre cancerous changes. I'm in Canada and have never spoken to insurer about any medical care so this makes me sad/angry that you have to put up with this when you are already dealing with cancer dammit.

    I wonder if your surgeon will intervene for you?

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  • Mucki1991
    Mucki1991 Member Posts: 294
    edited August 2017

    I have BCBS and had BMX left was cancer right was clean.. Maybe you could get an MRI to see if there is more there than just the 1/2 cm

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  • Icietla
    Icietla Member Posts: 1,265
    edited August 2017

    Oh dear. I think you should go ahead with the surgery as planned. Have the Hospital appeal that necessity determination after.

    Even if you get stuck for the difference, the difference, at insured rates, for a CPM coincident with a mastectomy surgery should not be nearly as much as for a separate mastectomy surgery.

    I am sure you would be more at ease having your planned surgery done sooner than later.

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  • Sam0623
    Sam0623 Member Posts: 110
    edited August 2017

    Mary,

    I am covered by a BCBS HMO in Michigan, and although I have not had my surgery yet- it appears it has been approved. I've also opted for a bilateral mastectomy, even though my cancer is only on the left and my genetic test results were negative. My surgeon mentioned to get the prophylactic side covered she codes it as something like "anxiety about developing second breast cancer". Maybe ask your Dr to resubmit using a different diagnosis code?

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  • Hopfull2
    Hopfull2 Member Posts: 418
    edited August 2017

    hi. Yes I believe it has to do with how your surgeon codes you.

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

    I can't imagine how it's their choice to cover bmx v umx. There was nothing wrong with my right breast but I chose to have it removed as well and have implants in both now. Insurance must cover any revisions I want to have done even just for symmetry by federal law. Something tells me they are mis-informed. I had mine done under BC covered California without a hitch. I would contact your state representative to get this ironed out. I think throwing out the words federal law would help as it's not a state thing. GL

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  • Marymac5522
    Marymac5522 Member Posts: 14
    edited August 2017

    After a sleepless night and a morning of phone calls and faxes, I discovered that my surgeon and the doctor/nurse at BCBS ironed it all out and it was ultimately approved last night or early this morning... the last business day before the surgery... really? why? It's been planned for some time! So now I can just hope the nodes are all AOK and that there is nothing more found.. since I am triple negative, the only other thing to do is chemo... I'm hoping we caught this so small, so early, that will not be necessary.

    Thank you!

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