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Insurance denial for a bi-lateral Mastectomy

GregStahl
Posts: 188
Joined: Apr 2010

My wife was diagnosed 4/22 with stage 1 ductal carcinoma T3 triple negative in one breast. When she talked to her insurance company (she works for a hospital and they are self insured) they said in her case a bi-lateral mastectomy was elective surgery for the one side and would not cover it. My question is, how many have been refused the bi-lateral and does anyone know or have a link to statistics showing occurances of cancer in the other breast after the first mastectomy?

greyhoundluvr's picture
greyhoundluvr
Posts: 402
Joined: Apr 2010

Greg - Self insured carriers may certainly be more restrictive than traditional group health carriers. I don't have statistics but am one of those who had a prohylactic mastectomy on the other side even though my oncologist said that I was eligible for just a lumpectomy on the side with cancer. My health insurance carrier paid for both sides (although my surgeon had me sign a waiver in case they didn't saying that I would pay). If your wife plans to appeal, you may want to talk with her oncologidt and surgeon to see if they will write a letter to support her decision. You may also want to go onto the websites of some of the major group health carriers (CIGNA, Aetna, United HealthCare, your state BCBS, and Anthem BCBS). Most of these carriers allow public access to their utilization review/medical policies and if you can show that group health carriers would typically pay, it may help persuade her self-insured carrier to cover it if that is her choice. Good luck!

Chris

Aortus's picture
Aortus
Posts: 967
Joined: Jan 2009

Greg,

My beloved Moopster had a mastectomy in November 2008, six days after being diagnosed with what turned out to be stage IIIa "triple (what a crappy term) negative" BC. She is now a year and a half out and strongly considering a prophylactic mastectomy on the other side. I'm 100% in favor of her decision, and her oncologists are supportive too.

If and when that time comes, I don't know if Moopy's insurance will pre-approve the surgery, but her docs seem to think that the "triple negative" is a strong argument in favor. I do know that the insurance company better go ahead and go along with Moopy's decision because she will make their lives an absolute hell if they don't. I hired HR Block to do our taxes this spring because I was sure we had a mountain of medical deductions. As it turned out, Moopster's insurance covered more than 99% of her bills. No itemized deduction... no complaints, either!

Best to you both and God Bless,
Joe (Aortus)

cathyp's picture
cathyp
Posts: 366
Joined: Dec 2009

My initial biopsy was IDC in one breast. I had previous radiation treatments 20 years ago for Hodgkins Lymphoma, therefore I elected a double mastectomy. My doctors pre auth it by saying "high possibility" for BC at a later date. Ended up the "good breast" had LCIS and I would have had another BC diagnosis down the road if I didn't do both. It was easier for me to get approval considering I was 22 times more likely than the avg woman to get BC. I would hope all ins covers prophylactics, reducing stress realted illness, mammo, ultrasound and biopsy costs down the road. Seems like a win-win for both consumer and insurer!

m-star's picture
m-star
Posts: 444
Joined: Apr 2010

I agree with greyhoundluvr. I would talk to her oncologist and surgeons to try and get them to write a letter of support.Make sure you photocopy any papers like this as you never know how many copies you need to send various people.
I'm sure if the onc and surgeons backed up your wifes decision,they insurance companies would be more likely to pay out.

I guess i'm lucky here in the UK as we have the National Health Service (NHS) so it all our health care gets covered as we pay our taxes and national insurance.

I elected to have prophylactic bilateral mastectomy in Feb this year as i was high risk of BC and my onc and breast consultant were 100% behind me. They do stress though that if they didn't think it was necessary,they wouldn't let people have it done. Luckily for me there was no question that it was the right thing to do.

Good luck and grind them down til they write you a letter! =)

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