Insurance Denial

Like leesa, I have no personal experience with the situation but I understand your distress. Insurance coverage/policies vary greatly, that’s for sure.I know there are laws mandating coverage for reconstruction but not familiar with other aspects of mandated coverage.

I read a post somewhere on bco regarding a medical center that would not do a mx on a healthy breast without significant medical justification. I know that there are more than a few in the medical world who are not at all comfortable with removing a healthy body without that same medical justifications.

I had my non-cancer breast removed during my surgery but I think the surgeon and mo justified it by noting there were calcifications in the healthy breast. Since it would need frequent monitoring, removing it altogether while I was already having the effected breast removed, and recon, seemed to make sense. Maybe they can look at your mammo closely and find a calcification or two?

Yes, I had to fight to have my supposedly healthy breast removed. I prevailed and the breast was not healthy. Medicare Advantage plan thru BCBS was my insurer and here's how we got it approved. The MO and I discussed my family history and I am not a good candidate for Tamoxifen or any AI's (I have MS). She asked if I had "Backache" and I said "Why yes I do and it's terribly painful". It was coded and notes indicate that due to my first mastectomy it threw my back out and shoulder pain. Surgery was 3 months after the first mastectomy and pathology showed Papillomatosis. You just need a supportive team and I too was surprised that it could be denied.

NC5, is there a reason a lumpectomy would not be enough? You haven’t posted anything regarding your status.

NC5, was it your breast surgeon or oncologist that did the peer to peer?

I won an appeal but for different circumstances but I gained an understanding of how it worked for me.

Any type of MD can be on the other end of the phone on the first appeal. Seriously, it can be a proctologist! I was stunned I was denied the first time around when my oncologist did the peer to peer. Who knows who she was talking to. It's certainly not their area of expertise. Most providers don't like doing appeals because it takes too much time out of their day. Insurance companies follow guidelines. The next step would take time on your end.

Call the insurance company and be prepared to be on hold and transferred around. Ask them to email you the guidelines for prophylactic mastectomy. The provider cannot request it must come from the patient. It's your right

Once you read the guidelines look for a loophole and write a letter based on that. Ask someone in the medical field to glance at it for you if u are not familiar with medical terminology. I also demanded an oncologist review it. On the second appeal I won. I even got the call on a Sunday.

It's rediculous that insurance companies dictate who gets care. I was so pissed. My oncologist said she has never ever had a patient win an appeal after she was denied. I've been an RN for 35 years and I'm not kidding once I'm ready to retire I would love this as a side job. Bring it on. Best wishes to you

You go, DebAl! I also cannot believe that some insurance companies are denying the option of removing the other breast. I didn't have any issue with my insurance company thank goodness. I cannot imagine the stress that would have added to the mix . I wonder if there has been any state by state legislation to force coverage? I might have to do some checking on that.