BInsurance denied alloderm as cosmetic

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AnnC2019
AnnC2019 Member Posts: 203
edited November 2020 in Breast Reconstruction

Hi,

I had a recent mastectomy and my insurance denied payment for the alloderm used to cradle the tissue expander. This has me worried about my upcoming exchange surgery. They denied payment because they said alloderm is cosmetic. That goes against what I have read that breast reconstruction is covered. I have BC/BS. Does anyone have insight into this? Also, they don't give official pre-approvals before surgery just verbal initials

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  • Beesie
    Beesie Member Posts: 12,240
    edited November 2020

    I think they are trying to pull one on you. Alloderm for breast enhancement surgery is not covered by insurance but Alloderm for breast reconstruction should be covered. They might have coded it the wrong way, or they may be hoping to slip it through if you don't complain.

    Complain. And ask you PS's office if Alloderm is ever not approved for breast reconstruction after a MX.

    I don't know who your insurer is, but you may be able to find their coverage details on-line. Here is the coverage from United Healthcare:

    Breast Reconstruction Post Mastectomy https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/breast-reconstruction-post-mastectomy.pdf

    "Tissue expansion is used to stretch the skin and tissue to provide coverage for a breast implant to create a breast mound. The procedure can be done with or without a dermal matrix including but not limited to Alloderm, Allomax, DermACELL, or FlexHD which are a covered benefit."

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  • WC3
    WC3 Member Posts: 1,540
    edited November 2020

    AnnC2019:

    I received a denial letter for reconstruction signed by an ENT and then when I called insurance and and also spoke to the insurance processor with my PS neither knew what it was about and insisted the claim had been approved. The the denial letter had been sent in error. I would call the insurance person at your surgeon's office and ask them to look in to it.

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  • muska
    muska Member Posts: 1,195
    edited November 2020

    I would call your plastic surgeon's office and ask them to deal with the insurance. Btw, I had BlueCross BlueShield of Massachusetts when I had my bilateral mastectomy with reconstruction (using alloderm) some seven years ago. They covered Alloderm no questions asked. I suspect your sugeon's office may not have included the correct code when submitting the claim.

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  • MinusTwo
    MinusTwo Member Posts: 16,634
    edited November 2020

    By all means, don't pay it. Likely it was coded incorrectly at the doc's office.

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  • AnnC2019
    AnnC2019 Member Posts: 203
    edited November 2020

    Beesie thank you for the information.

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  • AnnC2019
    AnnC2019 Member Posts: 203
    edited November 2020

    Thank you all for the information.

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